Documentation of Care Provided

1. 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?

2. 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

3. Format of Documentation • S O A P format • pharmaceutical care format • comprehensive vs. specific • pre-formatted form for site • pharmacy records vs. medical chart

4. Format of Documentation • Pharmaceutical Care Format • many ways of doing this • may depend on pharmacist and site

5. An Example of DocumentationPharmaceutical Care Format Drug-related issue/concern/problem Justification Recommendation Plan

6. An Example of Documentation If a letter to a physician to change therapy, may include the following: Drug-related issue/concern/problem Justification Recommendation

7. 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

8. 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

9. 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?

10. 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

11. Documentation… • SOAP note – what to include under each sub-heading (used by most health professionals) • Example of a Clinical Pharmacist’s Note

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

13. Documentation… • Exam purposes: • Chart Documentation • SOAP format • Pharmaceutical Care format Ensure that all relevant issue for the discussion of the therapeutic issue is included.