The document discusses documenting clinical pharmacy services. It states that documenting activities is essential for providing services and involves recording patient information, interventions, workload statistics, and quality indicators. The objectives of documentation are to improve patient care, communicate with other providers, demonstrate pharmacist accountability and assess service quality. Clinical activities that should be documented include information in health records, departments records, interventions, and workload/performance indicators.

1. Submitted To :
Dr. KANCHAN VOHRA
Assistant Professor
Submitted By :
Mohd. Rafi Bhat
DOCUMENTATION OF
CLINICAL PHARMACY SERVICES

2. Documenting activities is an essential
element of providing clinical pharmacy
services, it involves a standardised process of
recording patient- specific information,
clinical interventions or incidents,
professional actions as well as workload
statistics, quality improvement activities and
KPIs (key performance indicators). This
information may be collected and recorded
manually or via an electronic medication
management system.

3. Objectives
1.The primary reason for documenting clinical
activities is to improve the quality of each
patient’s care.
2.Documenting clinical activities in the patient’s
permanent health record is a way of
communicating with other health professionals
to support the continuity of care of the patient.
3.Documentation demonstrates the
accountability of the pharmacist and the
evidence of impact of the pharmacist’s services.

4. 4.The continuous and periodic
documenting of workload statistics
and KPIs aims to assess efficiency and
quality of pharmacy service provision
and may assist in strategic planning

5. Clinical activities documented include:
1. Information in the patient’s permanent health
record, i.e. NIMC (National inpatient medication
chart), MMP(Medication management plan),
health record or organisation specific form that is
filed in the patient’s health record
2.Patient- specific information as part of a
departmental record, e.g. patient meets funding
criteria for medicine.
3.Documenting clinical interventions and incidents,
workload statistics and KPIs should be carried out
in accordance with local policy and service
agreements.

6. 4.Other clinical activities should be recorded
when the information is useful in
determining the efficiency and quality of the
clinical service and to assist in strategic
planning.

7. Policy & Procedure
How information is documented will be dependent on
local policy and will be influenced by the nature of the
information and who the information is intended for.
This is applicable to all forms of documentation,
manual and electronic. Patient-specific information
may be documented:
• on the NIMC and associated medication charts
• on the MMP or equivalent
• directly in the patient’s health record.

8. Inpatient Medication Administration
Order
1.The NIMC is intended to ensure best
practice and assist in improving the steps in
the medication management cycle through
safer prescribing, dispensing and
administration of medicines and minimising
the risk of adverse medication events .
2.Pharmacists should be familiar with
the NIMC User Guide.

9. 3.Any annotations by the pharmacist should
be easily identified as being distinct from the
prescriber.
4.Organisation policy may allow for the use of
coloured ink, which should be easily visible
when charts are photocopied, faxed or
scanned.
5.If an annotation is made the pharmacist’s
signature, designation and contact details
should be clearly identifiable on that page.

10. 6.Check that adverse drug reactions (ADRs)
have been annotated appropriately on the
chart.
7.Ensure the ADR sticker is also on the
chart if ADRs are listed. If the patient is not
aware of previous ADRs, then the ‘nil
known’ box should be ticked and the
person documenting must sign, print their
name and date.

11. 8.The pharmacist should sign the
pharmaceutical review section at the bottom
of the NIMC to indicate the appropriateness of
all medicines ordered for that patient, e.g.
doses, drug interactions.

12. 9.The medication history documentation
section may be completed by the admitting
medical officer, nurse, pharmacist or other
clinician trained in medication history
documentation.
10.The NIMC provides space for minimum
information to be documented on admission.
Health

13. Medication Management Plan
1. It is essential that information relating to
the management of a patient’s medicines is
documented in a routine manner that enable
all healthcare team members (medical,
nursing, pharmacists) to have timely and full
access to assist in decision making.
2. This information should be documented
using a standardised format that forms part of
the patient’s health record.
3.This information may be documented in
either a paper-based or electronic format.

14. 4.Decisions regarding the use and format of
MMPs will depend on the organisation
5.The MMP should be kept with the active
medication chart(s) throughout the patient’s
admission . It should be available to and used
by other health professionals and the
patient/carer when possible. After discharge it
should be filed with the patient’s permanent
health record.

15. Specific information documented on a MMP or
other
report could include:
• history of presenting complaint and reason for
current admission
• assessment of the patient’s clinical problems
• plan for the management of the patient’s clinical
problems and therapeutic goals
• past and current medical and surgical problems

16. • details of allergies and ADRs, including
dates and descriptions of reactions and re-
exposure to the drug
•relevant laboratory parameter
• list of medicines at time of admission and
past medication history

17. Patient Health Record
Information documented in the health record is
intended to form a permanent record and to
supplement, not replace, verbal communication.
When making an entry in the health record:
• identify discipline (i.e. pharmacist), date and
time
• follow a logical sequence, e.g. SOAP method:
-subjective relevant patient details
-objective clinical findings
-assessment of the situation or clinical problem

18. -proposed management plan
• use only well-recognised abbreviations
(refer to an appropriate medical
abbreviations document)
• document the strategy for clinical review
and monitoring
• sign the entry, print name and designation
alongside signature and provide contact
details

19. Documenting the following details or activities
relating to medicines-related problems and
potential actions in the patient’s health record:
• information obtained from an accurate
medication history including an assessment of
patient adherence with the prescribed medicines
regimen
• identification of serious clinical problems with
discussion of the pharmacist’s assessment
• details of patient education and administration
and adherence aids provided

20. • provision of patient-specific medicines
information and specific therapeutic
information, e.g. Potential drug interactions
• recommendations for therapeutic drug
monitoring and evaluation of therapeutic drug
monitoring data
• ADR assessment and management
recommendation
• response to patient-specific questions from
other staff

21. Organization Specific Form
1.Organisations may choose to develop their
own standardised forms for recording patient-
specific information.
2.It is important that patient-specific
information is accessible to all members of the
healthcare team during the patient admission
and filed in the health record at discharge.

22. Clinical Interventions or addressed
medication-related problem
Previous versions of these standards have
defined a pharmacist intervention as any action
that directly results in a change in patient
management or therapy pharmacist clinical
interventions as: ‘the process of a pharmacist
identifying, and making a recommendation in
an attempt to prevent or resolve, a DRP(drug
related problem).

23. Departments should have a formalised policy
on documenting pharmacist interventions
Following information should be recorded
• medicine(s) involved
• date and patient demographic data
• treating unit/provider
• pharmacist identifier
• category of the DRP
• category of the pharmacist recommendation
• category of the action taken in response to
the DRP

24. QUALITY
ASSURANCE OF
CLINICAL
PHARAMCY
SERVICES

25. DEFINATION
Quality assurance can be defined as the
procedures which are used to set , promote ,
maintain and monitor the desired standards
for services and products

26. SIGNIFICANCE
The implementation of a quality assurance
programe will provide confidence that defined
tasks are carried out efficiently ,effectively
and according to the accepted standards of
professional ethics and knowledge.
It is a professional responsibility to ensure
that appropriate standards of clinical
pharmacy services are documented and
maintained.

27. GOALS
•To monitor and evaluate the quality of clinical
pharmacy services and standards of practice.
•To identify areas for improvement (question existing
practice)
•To provide a mechanism through which action is taken
to make and maintain these improvements
•To motivate clinical pharmacists by involving them in
the assessment and evaluation of their service

28. Establishment of a quality assurance
programme
Key requirements
1.Administrative support
-Establishment of appropriate departmental
goals
-Selection of pharmacists who are suitably
qualified and experienced to perform clinical
activities
-Commitment to continuing education of
pharmacists providing clinical services
-Allocation of resources necessary to perform
quality assurance

29. 2.Quality assurance co-ordination committee:
-consists of pharmacists providing clinical
services
-Should define-
The objective and scope of the programme
Acceptable standards of practice
Methods of evaluation and documentation to be
used
The review time table

30. Determining Priorities
•Priority should be given to those aspects of
clinical pharmacy which have the greatest
contribution to patient care (eg. TDM, patient
counseling, medication chart review)
•Each aspect of a section should be examined
detail to determine the critical components that
must be monitored, the ways in which quality
can be monitored or promoted and what
prerequisites are required.
•Areas to be targeted should include:

31. -Personnel: eg. Training and education, clinical
acumen
-Materials and products: eg. patient
profiles,drug utilisation review reports , ADR
reports
-Facilities: eg. Drug information support
-Procedures: eg. Documentation of intervention
and clinical services

32. Setting of standards
•Setting of standards and criteria should be
based on current practice
•Should be formulated and endorsed by
pharmacists to whom they apply

33. METHODS
1.Documentation of Procedures
2.Evaluation of Compliance
Audit of Documentation
 Patient drug profiles
 Endorsement on patient drug charts
and prescription
 Written drug information answers
 Drug utilisation reports
 ADR report
 Pharmacy intervention record

34. 3.Accompained Visits
evaluation on one to one basis using a
checklist based on previously agreed
standards
4.Questionnaire and / or interviews
5.Random Audits
6.Personnel Evaluation

35. Peer review by
Promoting professional development
Improving knowledge base
Providing a mechanism to establish , monitor,
review and maintain standards of practice
Identification and resolution of problems
Promoting liaison and communication
between pharmacists involved in clinical
services

36. CONCLUSION
 Quality Assurance Programme ensures
that quality of health care is achieved
and maintained in the given clinical
settings
 It also provides professional satisfaction to
the pharmacists
 Quality Assurance should be an integral
part of clinical pharmacy services.