Clinical Note Writing

1. Clinical Note Writing Pharmacy Department Dale Tucker, RPh, BCPS Elizabeth Cincotta, PharmD Detroit Medical Center Last Updated July 2005 by Julie Berman (DRH), Albert Bajjoka (HVSH), May Saba (CHM), Kim Tsilimingras (SGH), & Dale Tucker (HUH)

2. Goals and Objectives • Goal: To orient the pharmacist to writing consistently accurate and clear notes in patient charts. • Objective: To give the pharmacist experience in note writing in the chart and have the notes formally reviewed in conjunction with pharmacokinetic and anticoagulation instruction. Amount of detail may vary from site to site

3. Introduction • Why write notes? • Note variations • Pharmacokinetics • Anticoagulation • Note types • First notes • Follow-up notes • Note etiquette • Note QAs Amount of detail may vary from site to site

4. Why Write Notes? • Define/communicate issues • Discuss current and alternative therapies • Determine drug duration of therapy • Suggest drug changes • Inform about patient education or medication adherence history Amount of detail may vary from site to site

5. Types of Notes • Pharmacokinetic notes • Anticoagulation notes • Patient education notes • Renal dosing notes • TPN notes • Other medication notes Amount of detail may vary from site to site

6. First notes Include pertinent patient history Include reason for consult Include related lab values, vital signs, and culture results Assess medication regimen Make recommendations Follow-up notes Assess duration of therapy Update related lab values and culture results Assess medication regimen Make recommendations General Breakdown of Notes Amount of detail may vary from site to site

7. All First NotesSome sites may have a standardized sticker available • Date and time • Header: Pharmacy Services or Anticoagulation Dosing Service, etc. • Patient demographics (age, allergy status, height, weight) and history • Medications as appropriate • Reason for consult or indication for therapy being monitored • Pertinent lab values (BUN/Cr, CBC, cultures, etc.) • Plan and/or a recommendation • Signature and pager number Amount of detail may vary from site to site

8. Pharmacokinetic First Notes Some sites may have a standardized sticker available • Include patient’s temperature (Tmax, Tcurrent) • On ICU and BMT units include I/Os • Include culture results • Include pharmacokinetic parameters for aminoglycoside drugs • Include desired goal levels and plan or need for monitoring levels • Address any other antibiotics the patient is taking as per site requirements • Indicate that primary team is to monitor for signs/symptoms of nephrotoxicity or ototoxicity Amount of detail may vary from site to site

9. Anticoagulation First Notes Some sites may have a standardized sticker available • Include baseline or most recent as well as current INR/PT and/or aPTT if possible • Assess potential drug and dietary interactions • Include target values for INR and/or aPTT • Indicate when to monitor next INR or aPTT • Address all anticoagulants the patient is taking • Indicate MD/RN to monitor for signs/symptoms of bleeding Amount of detail may vary from site to site

10. All Follow-up Notes Some sites may have a standardized sticker available • Include reason for consult or indication for therapy being monitored • Note: The reason for therapy may change and needs to be evaluated with each note written, i.e., rule out pneumonia is not appropriate a week after the initial note • Indicate day of therapy and assess duration of therapy • Include updated pertinent lab values • Include a plan and/or a recommendation Amount of detail may vary from site to site

11. Pharmacokinetic F/U Notes Some sites may have a standardized sticker available • Include patient’s temperature • Update culture results • Report any drug levels with an interpretation of them and/or a recommended action • Indicate the times of the levels with reference to the time the dose was given • On ICU and BMT units include I/Os • Indicate that primary team is to monitor for signs/symptoms of nephrotoxicity or ototoxicity Amount of detail may vary from site to site

12. Anticoagulation F/U Notes Some sites may have a standardized sticker available • Include target values for INR and/or aPTT • Indicate the most recent CBC • Indicate plan for transition to oral warfarin such as DC heparin when INR at goal X2 days • Indicate primary team is to monitor for signs/symptoms of bleeding Amount of detail may vary from site to site

13. Note the Common Threads • Always be organized and neat • Always include reason for the consult or indication for therapy being monitored • Always update any lab values or culture results • Always include a plan and/or a recommendation Amount of detail may vary from site to site

14. “Political Correctness” • Use notes to communicate information pertinent to the care of the patient • Use only approved abbreviations when writing orders or notes • Do not argue a point in the notes: CALL THE PHYSICIAN • Avoid judgmental statements • Never write a note when emotionally upset Amount of detail may vary from site to site

15. DMC: Unsafe Abbreviations Amount of detail may vary from site to site

16. Word Choices • Recommend • When you are 100% sure of your recommendation • Suggest • When fairly certain of your decision • Consider • When you are even slightly hesitant about your recommendation Amount of detail may vary from site to site

17. DON’T USE Toxic Supratherapeutic Above therapeutic range Maximum High Bad Wrong USE Above goal for this patient and indication Not within desired range for this patient Word Choices Amount of detail may vary from site to site

18. DON’T USE Subtherapeutic Below therapeutic range Minimum Low Bad Wrong USE Below goal for the patient and indication Not within desired range for this patient Word Choices Amount of detail may vary from site to site

19. DON’T USE Abbreviations for terms (drug names, pharmacokinetic parameters) that are not approved by the hospital or that may have other explanations Word Choices Amount of detail may vary from site to site

20. DON’T USE Exact number for an estimated value (i.e., CrCl=46ml/min) USE Ranges (i.e., CrCl=40-60ml/min) Approximately 36ml/min Word Choices Remember, calculations are an estimate! Amount of detail may vary from site to site

21. Clinical Quality Assessment • To give a peer review of pharmacist communication in the chart and on the PMR • To evaluate the content of notes • To evaluate pharmacy monitoring record (PMR) for completeness • To compile data quarterly as a clinical quality indicator Amount of detail may vary from site to site

22. Peer Reviewed Quality Assessment • Everyone who writes notes • Has their notes evaluated by other clinical pharmacists • Is expected to evaluate and submit a QA of other clinical pharmacist’s notes (~10/month) • Submits QAs of pharmacist and non-pharmacist orders when discrepancies are noted such as “U” written instead of “units” • NOTE: submit QA for correct notes, too! Amount of detail may vary from site to site

23. QA Monitoring Form Amount of detail may vary from site to site

24. In Conclusion Be clear! Be accurate! Your notes are being read! Amount of detail may vary from site to site