Clinical Documentation

1. Clinical Documentation Pharmacy Department Dale Tucker, RPh, BCPS Harper University Hospital Hutzel Women’s Hospital Karmanos Cancer Hospital Rehabilitation Institute of Michigan Last Updated July 2005 with evaluation by Julie Berman (DRH), Albert Bajjoka (HVSH), May Saba (CHM), Kim Tsilimingras (SGH), & Dale Tucker (HUH)

2. 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

3. Summary • Why document • Who documents • When to document • What to document • Emphasis on near misses • How to document

4. 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

5. Who Documents? • All clinical pharmacists • All clinical pharmacy specialists • All supervisors • The pharmacy clinical coordinator • All pharmacy residents • All pharmacy students via preceptors

6. When to Document • A minimum of once a month at the end of the month, or • Can document weekly, or • Can document daily

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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

13. Documentation Worksheet

14. Documentation Worksheet

15. 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

16. Type in WORKLOAD Then press enter

17. Type 1 in the ACTION field and press enter

18. Enter chosen 7 digit number to report interventions or enter “?RX” to access choices then press enter 4 times

19. Enter appropriate number under billed doses then press enter 3 times

20. Repeat the previous 2 steps until all entries are completed

21. When done, “X” out of the entry screen

22. Enter “A” in the action field and press enter

23. How to Document? • Entries are now completed • Return to main menu

24. In Conclusion, Stand up and be heard Document often Document regularly