Documentation of Care Provided

1
Documentation of Care Provided

• Patients 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 elses note

11
Documentation

• SOAP note what to include under each
  sub-heading (used by most health professionals)
• Example of a Clinical Pharmacists 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.