Documentation Guidelines for Pharmacists
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Policy/Guideline/Standard: | Guideline | ||
| Title: | Documentation for Pharmacists | ||
| Published Date: | Pharmacy Connection January/February 2004 | ||
| Revised Date: | 2008 | Review Date: | 2012 |
| Key Words: | document, documentation, patient care | ||
| Related Topics: |  | ||
| Legislative references: | | ||
| College Contact: | Professional Practice | ||
| Purpose: | To assist pharmacists in meeting the expectations for documentation in pharmacy practice | ||
Simply documenting will not guarantee that the process will contribute to continuity of care…” (1)Documentation is a key element of every health professional’s standard of practice. It is an integral activity for physicians, nurses, and other health professionals involved in direct patient care. As pharmacists, it is also important for us to document our actions and dialogue with patients and/or their health providers, as it provides evidence of our contribution to patient care.
Documentation also enhances our contribution to other members of the health care team. Only in recent years has documentation received recognition as an important function of pharmacy practice. Now documentation is recognized as a critical component of the Standards of Practice. Operational Components 1.5, 1.7, and 1.8.2, identify situations where documentation is required when filling a prescription. Operational Components 4.3.1, 4.3.2, and 4.4.4 highlight the importance of documentation during non-prescription drug interventions.
Our goal for these guidelines is to establish our expectations for documentation in Ontario pharmacy practice. While the range of pharmacists’ documentation skills vary from minimal to extremely sophisticated, these guidelines are intended to help pharmacists to further develop these skills and processes as well as provide enhanced awareness.
These guidelines are intended to provide basic documentation expectations which will be the foundation on which future expectations will be based. Depending on the practice setting, more detailed documentation may be required than is set out in these guidelines.Scenario 1:A patient was receiving Atenolol 100 mg daily. When the patient returned to the pharmacy for a refill, the pharmacist noted that the patient appeared to be non-compliant as it was almost 190 days since the last refill. The patient explained that his physician had reduced the dosage to 50 mg daily.
The pharmacist documented this explanation, and when the request for a renewal was made, the correction of the dosage was verified and documented. As a result, any pharmacist that fills a future renewal can be confident of the accuracy of the change and will be able to ensure that their follow-up dialogue with the patient is focused on the change in dosage.Scenario 2:The patient has always had Erythromycin/Macrolide allergy on their record.
The patient has a prescription for Biaxin® and in discussion with the pharmacist, reveals that once in the past he had a small amount of nausea after taking an erythromycin product. The allergy notation was removed and a patient note line was entered reporting the removal of the allergy note. It also explained that mild nausea occurred after taking erythromycin stearate; also noted was the date the pharmacist received and noted this information.
PREAMBLE
Documentation should serve as your record of the critical thinking and judgement you used and to describe events or discussions that you have had with your patients and their caregivers. It will also help you and other members of your pharmacy team provide better patient care.It is important for you to note that you are creating a permanent health record every time you document. The following guidelines are designed to help (rather than dictate) how you can develop consistent rules and methods for documenting. Documentation establishes accountability and responsibility for professional activities. It is a key component in demonstrating how you exercise your professional judgement. Documentation should contribute to continuity of care and should be organized in such a way that the patient’s needs, the pharmacists’ actions, and patient outcomes are accurately described.
GUIDELINE 1
Documentation must be accurate and true. It should be clear, concise, and patient focused, including:
- Date
- Identification of person(s) involved
- Clear identification of the documenting pharmacist
- Patient condition or concern
- Patient history summary and their care plan if it is developed. (The record should acknowledge whether a care plan was available. In some instances, a care plan may be part of the patient record. If this is the case, you should acknowledge this fact in the documentation.)
- Information provided to or received from other caregivers
- Collaboration undertaken with other caregivers, including outcomes and/or proposed courses of action
- Pharmacist’s assessment, interventions, and recommendations where professional judgement was exercised
- Clear and established abbreviations that are common to all health care professionals
- Generic drug names, unless recording the brand name is required to avoid confusion
Documentation should not contain unfounded opinions or conclusions.Whenever drawing conclusions or making recommendations, supporting data should be recorded. (Unfounded observations, speculation or opinions should be avoided.)
GUIDELINE 3
Documentation should be completed promptly after providing care. It should be well organized and chronologically recorded.
GUIDELINE 4
All documentation must be legible and non-erasable. Written entries should be made in ink, not in pencil. Electronic entries should be non-alterable.
- Changes to any recorded information should include the source of the information to allow a complete audit trail
- In a manual record, cross out errors with a single line and initial
- Notes should not be deleted or removed from any files or records
GUIDELINE 5
Documentation must be kept confidential and be readily retrievable.
- Protect information from unauthorized access
- Establish a policy on information access in compliance with the Code of Ethics and privacy legislation
- Ensure the security and confidentiality of information that is transferred or released
PRINCIPLES OF DOCUMENTATIONIdentifying a patient problem or need and determining or anticipating appropriate outcomes are the foundation of documentation. The following questions form the basic principles related to documentation. These are also based on the expectation that anyone reading a documented record should be able to easily and clearly determine:
- What happened?
- To whom did it happen?
- Who made it happen or what caused the event?
- When did it happen?
- Where did it happen?
- Why did it happen?
- What was the outcome of the actions that were taken?
WHAT SHOULD I DOCUMENT?There are many opportunities in the course of your daily practice where documentation is beneficial (discussions with other health care professionals, agents, financial institutions, third parties, suppliers, etc.). Although the Guidelines for Documentation can be used at any time, the College is starting its focus on two general categories:
a) Patient Specific and
b) Prescription Specific.
1. Patient Specifica) Actual or potential drug related problems arising from both prescription and non-prescription medications*Operational Components 1.2, 1.5, and 1.7, of the Standards of Practice 2003 identify the expectations for documentation by pharmacists.Scenario 1:A pharmacist received a new prescription for a young woman for Wellbutrin® 150 mg., M: 90, Sig: iii tabs daily. When the pharmacist dialogued with the patient, the patient explained that she has been taking three tablets every morning for several months, from another pharmacy. Since the patient was going to return to pick up the prescription, the pharmacist had time to call the drug information centre, the manufacturer, and the physician to confirm the dosage. The doctor confirmed that the dose was accurate and that the patient could continue taking all three tablets together, although I q8h would be preferable. The pharmacist documented the following in the note section: “confirmed Wellbutrin® dosage (3 qam) with Dr…., DIRC, GSK, and the patient today. See original prescription #xxxxxx for more detail.” This documentation provides concise accurate information to any pharmacist who will fill or refill a prescription in the future. Scenario 2: When you cannot reach or talk to someone.It is Friday night at 7:30 when a discharged hospital patient presents himself to the pharmacy with a prescription for Atenolol with no strength indicated. Patient history reveals that the patient was previously on hydrochlorothiazide 50mg but the patient cannot remember whether he was to discontinue or continue the hydrochlorothiazide. It is likely that the pharmacist would attempt to call the doctor and contact the hospital, and also speak to the patient. Whether a prescription or other medication is dispensed would depend on the professional judgement of the pharmacist as a result of the interaction that would take place. Whatever the outcome of this interaction, the important element here will be the documentation provided in support of the final decision. The documentation should be recorded in a way that ensures another pharmacist can clearly understand what transpired and what actions were necessary.
b) Recommendation(s) for changes to drug therapy, dosage, duration and/or route of administrationDocumentation should encompass pertinent discussions with the patient and prescriber/health care provider.
- Patient education
- Contact information or activity
- Any communication which occurred or was attempted
- Information regarding drug use that is deemed important to patient care
- Drug or patient information pertinent to the situation
Scenario 2:While the pharmacist was demonstrating the proper technique for using a Flovent® inhaler, the patient stated that the inhaler was to be sprayed directly into the nostrils, not the mouth. Upon verifying these instructions with the doctor, the following documentation was added to the note section in the profile: “Verified with the doctor that patient is to use Flovent in the nose as directed”.Documentation should clearly identify the situation, an analysis of the situation, the outcome of actions taken, the patient's understanding of the situation, then a plan of action to resolve the situation, following up on actions to be taken, responsibilities for actions to be taken and final resolution to close documentation.
2. Prescription Specific
a) Legislative requirements (reduced quantities, no sub etc.)Scenario 1: A patient has just brought a prescription in for 180 tablets of Losec® 20mg. He cannot pay for this quantity and may not use all the tablets. He asks the pharmacist if he can have only 30 at a time. The patient must sign or initial the request to dispense less than the authorized quantity (DIDFA s.9) on the prescription. Although not required, it is recommended that the pharmacist also document the reason for the reduced quantity.
b) Prescription clarification (dosage, drug etc.)
Scenario 2: A patient brings in a new prescription for Atenolol 12.5mg daily. On reviewing his history, you notice that he has been receiving Atenolol 25mg. Upon questioning the patient, all he can recall is that he saw the doctor for a regular check up and the doctor wants him to continue taking his Atenolol once a day and can't remember if the doctor changed the dosage.Upon checking with the doctor, the doctor did reduce the patient’s medication. The pharmacist should document that the physician was called and the dosage verified. In addition, the dialogue with the patient should be documented to indicate the patient was informed and understood that they will only be taking half a tablet.
DOCUMENTATION STYLES
A range of documentation styles are acceptable: these include unstructured notes, semi-structured notes, and systematic records using established codes. Each style has certain advantages and disadvantages. Pharmacists must exercise professional judgement in choosing and consistently using a specific documentation style which is most appropriate, effective, and efficient in each situation and practice setting.
1. Unstructured notes are free-form records of patient encounters and care. These notes must, at a minimum, be dated and signed, and should conform to general conventions of appropriate language use (employ correct grammar, punctuation and avoid unnecessary abbreviations or short forms, etc.). The advantages of unstructured notes are that they can be quickly written and can provide an “impressionistic” overview of a situation. Disadvantages of unstructured notes are that they are often incomplete, lack consistency, and have limited value as communication with other health care providers.
2. A variety of systematic documentation systems have been proposed for pharmacy; such as SOAP and FARM. These acronyms refer to the general categories of information which are documented: SOAP information is documented under the categories of Subjective (findings), Objective (findings), Assessment, and Plan. FARM categories are Findings, Assessment, Recommendations, and Management (and follow-up). Both systems are well recognized and widely used. Systematic documentation has the advantage of encouraging completeness and consistency, as well as improving organization of thought. However, in some circumstances, such documentation can prove to be time-consuming, onerous and confusing (particularly if a pharmacist is unclear as to how to categorize certain types of information).
3. Semi-structured approaches use a blend of both systematic and unstructured documentation systems. In these approaches, pharmacists may complement a SOAP or FARM note with additional free-form text to either provide more in depth information or to provide unusual and important details that may not be easily categorized elsewhere. Semi-structured notes can have the same advantages of both unstructured and structured notes, although they often take more time to compose, and may not be as clear and consistent as structured notes.Structured notes may be most appropriate in circumstances where monitoring and follow up are required. Semi-structured or unstructured notes may be more appropriate where general impressions are noted, but no specific action on the part of the pharmacist is required at the time.
