Documentation of Care Provided

• Patient’s care - who should do it?

• WHY DOCUMENT?

• When should it occur?

• Where should it be documented?

• How should it be documented?

• What should be documented?

Documentation of Care Provided

• Issues to consider

- comfort level

- time it takes

- restrictions at site (where, what, who)

- need to use it! (for follow-ups)

- responsibility - signing off a patient

Format of Documentation

• S O A P format

• pharmaceutical care format

• comprehensive vs. specific

• pre-formatted form for site

• pharmacy records vs. medical chart

Format of Documentation

• Pharmaceutical Care Format – many ways of doing this– may depend on pharmacist and site

An Example of DocumentationPharmaceutical Care Format

Drug-related issue/concern/problem

Justification

Recommendation

Plan

An Example of Documentation

If a letter to a physician to change therapy, may include the following:

Drug-related issue/concern/problem

Justification

Recommendation

What should be documented?

• Any information pertaining to drug therapy of the patient (real or potential)

• Should include patient, drug, or disease information that confirm the validity of the DRP

• Should succinctly state the specific recommendation(s) for changes in drug selection, dosage, duration, route

What should be documented?

• Recommendations for monitoring of the response to drug therapy including the tests, frequency, interpretation of test

• Activities and follow-up to be conducted by pharmacist

What not to include in the documentation?

• Suggestions to change or monitor therapy without providing specific individualized parameters not useful (e.g. check INR?)

• Unrealistic recommendations? (option not available at site?)

• Unknown abbreviations

• Trade names for single products?

What not to include in the documentation?

• Health care record is a legal document

• Must accurately reflect care provided

– Do not add information at a later date

– Do not add to someone else’s note

Documentation…

• SOAP note – what to include under each sub-heading (used by most health professionals)

• Example of a Clinical Pharmacist’s Note

Documentation…

• Pharmaceutical care based upon a thorough review of systems; however, only include info. pertinent to the therapeutic issue being discussed

Documentation…

• Exam purposes:– Chart Documentation

• SOAP format• Pharmaceutical Care format

Ensure that all relevant issue for the discussion of the therapeutic issue is included.