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Pharmacist Documentation in a Medical Record (Chart)
BACKGROUND
Documentation has been defined as "the written summary of the pharmacist's description, evaluation, and recommendation of an individual patient's drug-related problems that becomes part of the patient care record."
Written documentation needs:
A consistent title, date and time, consistent format, signature/title, contact phone number, consistent placement in the chart or in the store's records
To be risk management sensitive, use the 5 "C's"
Correct (accurate), complete, concise, consistent, and cautious.
Points to consider in your documentation note: (from the class video)
It should be legible, written in ink, succinct, objective and non-judgmental.
Use approved abbreviations.
Do not assess blame or present worst-outcome scenarios. (just state the facts of what happened - should name people involved, but don't try to assess who is at fault)
Use names when you have communication with a specific person.
Do not directly disagree with another. (Nurse Jones was incorrect when she said...)
Do not force someone else to take action.
Do not refer to an incident report in note. (lawyers can then subpoena)
No guarantees.
If you are not going to recommend action, don't write a note about it.
Goals should be realistic and consistent with those of other health care providers and the patient.
INSTRUCTIONS
Use principles from the documentation video and handouts given in class to write formal documentation notes.
Use wording and formality adequate to make the note legally appropriate (risk-management sensitive), including labeling and contact information, and also be complete enough that other pharmacists at your store can read it and understand what occurred.
Documentation of Discharge/Patient Counseling
Don't need all specifics, just that you did it.
For example if you usually put specifics, then anything you don't specify is assumed not done (proves non-occurrence).
On the other hand, just saying that you counseled the patient depends on your established standard of practice to prove that you do normally talk to patients about the specifics.
Do note the drugs, and the patient's level of understanding - were they able to explain it back to you?
Also, note that patient received written patient education materials (and where they came from).
Documentation of an incident report
Kansas pharmacy law states that a retail pharmacy incident report must contain the following:
the name, address, age, and phone number of any complainant, if available;
the name of each pharmacy employee and the license number of each licensee involved;
the date of the incident and the date of the report;
a pharmacist's description of the incident;
the prescriber's name and whether or not the prescriber was contacted; and
the signatures of all pharmacy employees involved in the incident.
Documentation of an CQI Report
Unlike an incident report, the purpose of a CQI report is to assess errors that occur in the pharmacy and should include a description of steps taken or to be taken to prevent a recurrence of the incident.