Download - Clinical Documentation
Clinical Documentation
Pharmacy DepartmentDale Tucker, RPh, BCPSHarper University Hospital
Hutzel Women’s Hospital
Karmanos Cancer Hospital
Rehabilitation Institute of MichiganLast Updated July 2005 with evaluation by Julie Berman (DRH), Albert Bajjoka (HVSH),
May Saba (CHM), Kim Tsilimingras (SGH), & Dale Tucker (HUH)
Goals and Objectives
Goal: To document all interventions made by a pharmacist related to medication usage and safety
Objective: To apprise every pharmacist of the system for recording all interventions made
Summary
Why document Who documents When to document What to document
– Emphasis on near misses How to document
Why Document?
Use as an indicator of medication safety and error reduction
Document impact of pharmacy clinical services throughout the DMC system
Note that appropriate transitions such as from IV to PO medications can also indicate a cost savings
Who Documents?
All clinical pharmacists All clinical pharmacy specialists All supervisors The pharmacy clinical coordinator All pharmacy residents All pharmacy students via preceptors
When to Document
A minimum of once a month at the end of the month, or
Can document weekly, or Can document daily
What to Document?
Number of new anticoagulation consults completed
Number of new pharmacokinetic consults completed
Number of 30 minute increments spent on patient care rounds
Number of other new consults completed: Dofetilide, TPN, etc.
What to Document?
Number of near misses including– Initiation of drug therapy– Change to alternative drug– Dosing changes– Avoidance of a major drug interaction– Duplication of therapy with potential toxicity– Order clarification– Prescriber error
What to Document?
Near misses are important – They are any interventions which avoid a
potentially hazardous situation– They are interventions which are used to
compare pharmacist activities between DMC sites
– They are the targeted indicator for pharmacist interventions and reported to the Medication Safety Committee
What to Document?
Number of 10 minute increments spent on chart reviews including– General chart reviews– Collection and assessment of daily labs or
tests– Labs/levels ordered or discontinued– Non-formulary changes– IV to PO administration– TPN changes
What to Document?
Number of days on vacation or off clinical coverage (for clinical specialists)
Number of ADE/Dr Quality reports completed
Number of 30 minute increments spent on administrative duties including– Committee work, minutes, and reports– Documentation– Monthly unit inspections
What to Document?
Number of 60 minute increments spent initiating or working on research protocols
Number of 60 minutes increments spent on education– Attending or giving lectures
– Resident or student teaching
– Medline/literature searches
– Paperwork, grading, etc
How to Document?
From the MS Meds main menu enter 4.1.3 and hit enter
Type in “WORKLOAD” then enter The next 7 slides indicate the
documentation procedure
Enter chosen 7 digit number to report interventions or
enter “?RX” to access choices then press enter 4 times