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Documentation of Pharmaceutical Care

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38 views24 pages

Documentation of Pharmaceutical Care

Uploaded by

amanfatima
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Component of Clinical Pharmacy.

Documentation
Mr. Muhammad Zeeshan Munir

Good Reads:
Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R. Matzke, Barbara G.
Wells, L. Michael Posey
https://accesspharmacy.mhmedical.com/content.aspx?
bookid=462&sectionid=41100773#7966572
Introduction
“ If it isn't documented, it isn't done! ”
Cohen

“If you are not documenting the care you provide in a comprehensive manner,
then you do not have a practice.”
Cipolle, Strand and Morley

• Documentation of pharmaceutical care services is


demonstration of clinician competence.
communication among health-care providers
evidence of contributions to patient care.
• Accurate/consistent documentation of clinical
observations, decisions, actions/interventions
intended by the pharmacist.

• Technology is assisting the pharmacist to


accurately and consistently document the care.
Importance of DOCUMENTATION
• Provides a mechanism for assuring the flow of
patient information from encounter-to-encounter
and from provider-to provider.
• Creates a permanent written record for legal
purposes.
• Useful in workload management to maximize the
use of existing personnel.
• establish the need for pharmacist in the channel of
distribution for prescription medications.
Joint Commission on Accreditation of Healthcare
Organizations (JCAHO)

• has included documentation as a key clinical


quality indicator in a medication-use monitoring
system

• Schaff RL, Schumock GT, Nadzam DM. Hosp Pharm 1991; 26:326. 8. Rupp MT. Am Pharm
1992; NS32:79.
3 categories of information:
• Health care provider should document 3
categories of information.

(a) The data used to make the decisions.


(b) The decisions made for and with the patient
(c) The actual outcomes that result from those
decisions
What To Document
• Functions performed by pharmacist. such as
obtaining medication histories
counseling patients
performing patient assessment and
monitoring.
conducting medication regimen reviews
providing medication information
patient's medication-related information
history of medication usage
history of refills
Forces Affecting Clinical Documentation
• Need for enhanced communication among
healthcare providers.
• A focus on reducing the potential medical errors
and preventable medication-related morbidity.
• The emergence of electronic medical records
(EMRs)/electronic health records (EHRs) in
healthcare.
• The desire of patients to obtain healthcare
information in a more convenient manner.
Elements to Be Documented by the Pharmacist
Essential Patient identifier.
Date of birth
Sex
Contact information
Allergies and adverse drug reactions
Medical problem(s), current and past
Prescription, nonprescription/alternative medications (history and adherence)
economic situation
History of present illness
Assessment (conclusions reached by the pharmacist )
Plan(s)/action(s) to correct problem(s
Monitoring plan and follow-up

To be Family history.
included if Social history.
relevant Objective information (e.g., vital signs).
Ethnic background.
Special needs of patient.
Non medication therapy

Currie JD, Doucette WR, Kuhle J, et al. Identification of the essential elements in the documentation of pharmacist-provided care. J Am Pharm
Assoc 2003;43:41–49. [PubMed: 12585750]
Documentation Guidelines
• The American Society of Health-System Pharmacists (ASHP) guidelines surrounding
the documentation.

• The Royal Pharmaceutical Society of Great Britain guidelines for pharmacists'


documentation

ASHP Council on Professional Affairs. ASHP guidelines on documenting pharmaceutical


care in patient medical records. Am J Health Syst Pharm 2003;60:705–707.

Royal Pharmaceutical Society of Great Britain. Guidance on recording interventions.


2006. http://www.rpsgb.org/pdfs/recinterventionsguid.pdf.
SOAP notes
progress notes reflect the four types of information that are known
as the SOAP approach.

used in the clinical training

provides a simple, logical structure for documenting clinical


encounters with patients

S = subjective findings
O = objective findings
A = assessment
P = plan
S = subjective findings.
• description of the problem and the associated symptoms in the
patient’s own words.
• Leads to the recognition of a pharmacotherapy problem or
indication for pharmacist intervention.
• Subjective data are open to individual interpretation, whereas
objective data are easily quantified.

• Examples includes
chief complaint
duration or severity of symptoms.
O = objective findings.
• includes observations made and data
collected/considered by the caregiver that is relevant
to the problem.
• physical exam or assessment, laboratory data.
• leads to, the recognition of a pharmacotherapy
problem or indication for pharmacist intervention.

• Examples of objective information include laboratory


– data, weight , height , blood pressure, and pulse.
• Practice Example:

Patient presents to the pharmacy in acute distress


complaining of flu-like symptoms for the past 2
days. Complexion is pale, skin is warm and dry to
the touch, temperature is 101° F orally.

Subjective Information?
Objective Information?
“S/O Findings.”

• Sometimes data is not clearly delineated as


subjective or objective.
• In these instances, the subjective and objective data
may be combined as a single section, labeled “S/O
Findings.”
• contain verbal quotes from the patient or those
close to the patient.

• “I feel hot and achy, and I have a splitting headache,”


• “She has been complaining of fever and headache
for a couple of days.”
A = assessment .
• Allows the caregiver to express his/her net
conclusion/opinion about the problem based on
the subjective and objective information.
• assessment states the physician's working
diagnosis and/or possible explanations for the
patient 's medical problem.
• In the pharmaceutical care model , however ,
diagnosis is not normally within the pharmacist 's
scope of practice.
P = plan
• Recommended course of action based on the new
information being considered by the caregiver.
• Include revising a previous plan or establishing a new
one
• recommended treatment, patient
education/instruction.
• In the medical model , the plan states the physician's
intended drug regimen(s), surgical procedures, and/or
diagnostic tests.
• In the pharmaceutical care model , pharmacists may
not have the authority to initiate or alter drug therapy
ABBREVIATIONS AND SYMBOLS
• Improve the accuracy of documentation while
conserving provider time and documentation
space.
• Many commonly used acronyms, symbols, and
medical abbreviations have multiple uses and
interpretations.
Ideal Documentation System
• Characteristics of ideal Documentation systems and
applications.
easy to use.
Portable.
produce useful reports
allow for knowledge sharing with other providers.
comprehensiveness.
affordable cost.
time efficiency.

survey conducted on 106 community pharmacists providing expanded


pharmaceutical care services in North Carolina in 2003.
Communication of Documentation and Findings

• Patient’s information should be made available to


other healthcare providers for review.
• One patient may have several patient files at
different sites of care.
• it is critical to determine what information must be
passed on to fellow healthcare providers.
• Properly documentation assists other pharmacists
during follow-up appointments.
Flow of information in Different settings.
Pharmacy To Community pharmacist often possesses valuable patient
Pharmacy information by virtue of seeing the patient regularly .

Pharmacy To Physician Pharmacists are in position to refer patients back into the
healthcare system for attention they may be in need of.
Pharmacist-initiated contributions in achieving defined therapeutic
objectives and/or identification/avoidance of DRPs must be
documented and shared alike.
Pharmacy To Patient Pharmacist’s recommendations to the patients should be
documented.
Technology and Documentation
• Electronic medical records (EMRs)/electronic health
records (EHRs) assist in enhancing the communication
among providers in all settings.
• allows enhanced decision making, and the ability to follow
up.
• facilitate the generation and transfer of patient
documentation. …Internet can transfer information over
greater distances.
• limit errors and control costs.
• guide future practices and policies.
• specialty software allow healthcare
practitioners to document information in an
electronic format.
• Interventions often need to be shared with
other pharmacists at shift changes, transfer of
patients from one care area to another, or
even transfer of patients to new health
systems altogether.
• e-mail can be used as vehicles to
communicate not only among healthcare
providers but also with patients.
Pharmacist training for documentation
• training related to
– why documentation is necessary
– how to document.
– use of technology to assist in the documentation process.
• The training of support staff, such as pharmacy technicians,
because these individuals can assist.
• training must be specific to the respective practice
environments of pharmacists
• For example, access to healthcare providers, medical records,
laboratory data, and patients is more common in hospital
pharmacy practice than in community pharmacy

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