Systems of documentation and record keeping in clinical pharmacy

1. SYSTEMS OF DOCUMENTATION AND
RECORD KEEPING IN CLINICAL
PHARMACY
Kenneth Bitrus David
Pharmacy Department,
National Ear Care Centre Kaduna
28th January, 2020
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2. Presentation Outline
• Introduction
• Systems of Documentation
• Types of Records in Clinical Pharmacy
• Formats for Clinical Documentation in Pharmacy
• How to use a diplomatic style
• Legal Considerations
• Conclusion
• List of References
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3. Introduction
• Pharmaceutical care is the responsible provision of medication-
related care for the intention of achieving definite outcomes that
improve a patient’s health status (Helper and Strand, 1990).
• Documentation should be:
• complete,
• Complementary,
• compelling with supportive evidence, and
• Systematic to complement oral communication among providers
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4. Systems of Documentation
• Several documentation styles can be adopted to
record pharmacist interventions, including
unstructured notes, semistructured notes, and
systematic records (Rovers et al., 1998)
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5. Types of Records in Clinical
Pharmacy
• Patient Record/ Documentation
• Inventory Record/ Documentation
• Administrative Record
• Financial Record
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6. • Systematic documentation styles include:
• SOAP (subjective, objective, assessment, plan),
• TITRS (title, introduction, text, recommendation,
signature), and
• FARM (findings, assessment, recommendations or
resolutions, management).
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7. How to include necessary
information but still be concise:
• Include information the physician needs to make a
decision about following your recommendation
• Consider using plain language to make it easy to read
your notes quickly (ie. one or two syllable words
instead of three or four syllable words, a few
examples below):
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8. Rather than this: Try this:
Notwithstanding In spite of
Accomplished Finished
Circumvent Avoid
Commence Start
Anticipate Expect
Endeavor Try
Ascertain Find out
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9. • Avoid:
• Unnecessary words
• Unauthorized abbreviations
• Deadwood expressionsRather than this: Try this:
am of the opinion that Think, believe
despite the fact that though
For the purpose of For
It is recommended that I recommend that
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10. To ensure that the record accurately reflects the
care provided to the patient the following points
should be considered:
• Documentation should occur immediately after the activity. Do
not add information out of sequence at a later date. If
documentation of an intervention is delayed, an indication that the
note is a “late entry” can be made.
• Ensure that writing is clear, logical and precise.
• Communication should be diplomatic with an appropriate tone.
• All abbreviations used should be clear and common to all health
care providers.
• All documentation must to legible and non-erasable.
• If an error is made in a manual record, the error may be crossed
out with a single line and initialized.
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11. How to use a diplomatic style (ie. how to avoid having the
identification of drug-related problems come across like
criticism):
• Use terms like:
• • May benefit from
• • May improve with
• • Suggest
• • Consider
• • May no longer require
• • Patient unlikely to comply with
• • Patient would prefer
• Avoid wording like:
• • Wrong
• • Unnecessary
• • Must
• • Patient does not want
• • Inappropriate / not appropriate
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12. Legal Considerations
• It is important for you to note that you are creating a
permanent health care record every time you
document.
• The medical record is a legal document.
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13. Name : Hospital No : Age : Gender : M / F
Ht/Wt : DOA : Ward/Bed :
Chief Complaint:
History of Present Illness
Past Medical History: Review of system
BP: mmHg RR: b/min
PR: p/min
T: OC
Social/Family History:
Smoking
Alcohol
Drug
Abuse
Pregnant
Past Medication History: Compliance Evaluation:
Diagnosis/Surgical Procedure:
Pharmacist name;
Signature/Date:
PHARMACY DEPARTMENT, XYZ HOSPITAL, KADUNA
PHARMACOTHERAPY REVIEW FORM
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14. Date : Pharmacist rounds
Ward : Number of cases clerked
Number of cases reviewed
Number of patients in ward
Number of medication history taken
Interventions Description No. of
intervention
No. of interventions
accepted
Request or information provided No. Total
(1)
Incomplete prescription
Patient Data Adverse drug Reaction
Drug Drug interaction
Dose Drug indication
Frequency General product information
Duration
Dr’s sign TOTAL INFORMATION
PROVIDED
(2)
Incorrect
/inappropriate
/inadequate drug regimen
Drug
Dose
Frequency
COUNSELLING Number
of
patients
Duration
(3)
Inappropriate prescription
Polypharmacy Bedside counselling
Contraindication
Discharge counselling
Drug interaction
Incompatibilities
TOTAL NUMBER OF
INTERVENTION
PHARMACY DEPARTMENT, XYZ HOSPITAL, KADUNA
CLINICAL PHARMACY REPORT FORM
A: WARD PHARMACY ACTIVITY
B: INTERVENTIONS/REQUESTS ENCOUNTERED
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15. Conclusion
• Documentation in a universal format allows for
communication among health care practitioners.
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16. References
• Bayliff, C., & Bajcar, J. (1997). Direct patient care
curriculum: Pharmaceutical Care Education Modules,
• Hepler CD, Strand LM. Opportunities and
responsibilities in pharmaceutical care. Am J Hosp
Pharm. 1990; 47:53343.
• Rovers JP, Currie JD, Hagel HP et al. A practical
guide to pharmaceutical care. Washington, DC:
American Pharmacists Association; 1998.
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17. 17
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Thank you for
Listening
Your Comments and
Questions are welcomed