System Of Documentation In Pharmaceutical Care (PC)

The professional actions of pharmacists that are intended to ensure safe and effective use of drugs and that may affect patient outcomes should be documented in the patient medical record (PMR). When such written documentation is placed in the patient’s primary medical record it not only communicates pharmacotherapeutic evaluations and treatment recommendations but also serves as a record of pharmaceutical care. These guidelines describe the kinds of information pharmacists should document in the PMR and how that information should be documented.

System Of Documentation

Pharmaceutical care is the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient’s quality of life. A core principle of pharmaceutical care is that the pharmacist accepts professional responsibility for patient outcomes. Integrating pharmaceutical care into a patient’s overall health care plan requires effective and efficient communication among health care professionals. As an integral member of the health care team, the pharmacist must document the care provided.

Principles Of Pharmaceutical Care Documentation

1. Patient records support the continuity of care and collaboration between and among health professionals;

2. The documentation of patient care optimizes decision-making, helps to reduce duplication of services and demonstrates the registrant’s decision-making process;

3. Good documentation has four important characteristics. It should be:

1) factual;

2) complete;

3) current (timely); and

4) organized.

Importance Of Pharmaceutical Care Documentation

Documentation is vital to a patient’s continuity of care and demonstrates both the accountability of the pharmacist and the value of the pharmacist’s services. The PMR’s primary purpose is to convey information for use in patient care;

i. It serves as a tool for communication among health care professionals.

ii. Information in the PMR may also be used in

a. legal proceedings (e.g., as evidence),

b. education (e.g., for training students),

c. research (e.g., for evaluating clinical drug use), and

d. quality assurance evaluations (e.g., to ascertain adherence to practice standards).

Patient Record

A patient record is the complete account of a patient’s care, including: the patient profile; patient and provider identifying information; data collected; assessment; notes documenting critical thinking and judgement, recommendations, interventions and discussions between registrants, other health care providers and patients; and prescriptions, records and reports that pertain to the patient’s care.

Type Of Pharmaceutical Care Documentation

Pharmaceutical care documentation generates three types of records namely:

i. pharmaceutical care patient chart, created primarily for the practitioner's use;

ii. patient's personalized pharmaceutical care plan, generated for the patient's use; and

iii. practice management report that is used to manage the practice.

These records can be maintained manually, electronically or a combination of both.

Information For Documentation

Examples of information a pharmacist may need to document in the PMR include, but are not limited to, the following:

1. A summary of the patient’s medication history on admission, including medication allergies and their manifestations.

Read Also: Medication Reconciliation Process

2. Oral and written consultations provided to other health care professionals regarding the patient’s drug therapy selection and management.

3. Physicians’ oral orders received directly by the pharmacist.

4. Clarification of drug orders.

5. Adjustments made to drug dosage, dosage frequency, dosage form, or route of administration.

6. Drugs, including investigational drugs, administered.

7. Actual and potential drug-related problems that warrant surveillance.

8. Drug therapy-monitoring findings, including

a. The therapeutic appropriateness of the patient’s drug regimen, including the route and method of administration.

b. Therapeutic duplication in the patient’s drug regimen.

c. The degree of patient compliance with the pre-scribed drug regimen.

d. Actual and potential drug–drug, drug–food,drug–laboratory test, and drug–disease interactions.

e. Clinical and pharmacokinetic laboratory data pertinent to the drug regimen.

f. Actual and potential drug toxicity and adverse effects

g. Physical signs and clinical symptoms relevant to the patient’s drug therapy.

9. Drug-related patient education and counseling provided.

System Of Documentation

Systematic documentation has the advantage of encouraging completeness and consistency of data presentation, as well as improving organization of thought. However, in some circumstances, documentation can prove to be time-consuming, onerous, and confusing (particularly if a pharmacist is unclear as to how to categorize certain types of information). There are a range of documentation styles to choose from that may address this issue, including the use of unstructured notes, semi-structured notes, and the creation of systematic records using established codes. Each style has certain advantages and disadvantages and the appropriate approach should meet the needs of the specific practice site.

1. Unstructured notes are free-form records of patient encounters and care. These notes must be dated and at a minimum identify the registrant who is making them. The notes should also conform to general conventions of appropriate language use, including the use of accepted abbreviations in a pharmacy setting. The advantages of unstructured notes are that they can be quickly written and can provide an ‘impressionistic’ overview of a situation. Disadvantages of unstructured notes are that they are often incomplete, lack consistency, and have limited value as communication with other health care providers.

2. Examples of approaches to documentation include SOAP, FARM, DRP, DAP and DDAP. These acronyms refer to the general categories of information which are documented:

SOAP: information is documented under the categories of Subjective (findings), Objective (findings), Assessment, and Plan;

FARM: categories are Findings, Assessment, Recommendations, and Monitoring (and follow-up);

DRP: stands for Drug-Related Problem, Rationale, and Plan;

DAP: is Data, Assessment, and Plan;

DDAP: refers to Drug-Related Problem, Data, Assessment, and Plan.6

Other documentation approaches may be used as long as they are consistent with the therapeutic thought process.

3. Semi-structured approaches use a blend of both systematic and unstructured documentation systems. In these approaches, pharmacists may complement a structured note with additional free-form text to either provide more in depth information or to provide unusual and important details that may not be easily categorized elsewhere. Semi-structured notes can have the same advantages of both unstructured and structured notes, although they often take more time to compose, and may not be as clear and consistent as structured notes. Structured notes may be most appropriate in circumstances where monitoring and follow up are required. Semi-structured or unstructured notes may be more appropriate where general impressions are noted, but no specific action on the part of the pharmacist is required at the time.

Documentation by pharmacists should meet established criteria for legibility, clarity, lack of judgmental language, completeness, need for inclusion in the PMR (versus an alternative form of communication), appropriate use of a standard format (e.g., SOAP [subjective, objective, assessment, and plan] or TITRS [title, introduction, text, recommendation, and signature]), and how to contact the pharmacist (e.g., a telephone or pager number).

The authority to document pharmaceutical care in the PMR comes with a responsibility to ensure that patient privacy and confidentiality are safeguarded and the communication is concise and accurate. Nonjudgmental language should be used, with care taken to avoid words that imply blame (e.g., error, mistake, misadventure, and inadvertent) or substandard care (e.g., bad, defective, inadequate, inappropriate, incorrect, insufficient, poor, problem, and unsatisfactory). Facts should be documented accurately, concisely, and objectively; such documentation should reflect the goals established by the medical team.

Documentation of a formal consultation solicited by a physician or other health care provider may include direct recommendations or suggestions as appropriate. However, unsolicited informal consultations, clinical impressions, findings, suggestions, and recommendations should generally be documented more subtly, with indirect recommendations presented in a way that allows the provider to decline the suggestion without incurring a liability. For example, the phrase “may want to consider” creates an opportunity for the suggestion to be acted upon or not, depending on presenting clinical factors.

The SOIP, later changed to the well-known SOAP (subjective, objective, analysis, plan), was originally designed by Dr. Lawrence L. Weed for medical doctors. The SOAP format used by clinicians goes like this.

Subjective data: Any information that a patient provides, such as complaints or symptoms, as well as the pharmacist's perceptions of the situation

Objective data: Any patient vital signs, laboratory test results, and physical examination findings. The pharmacist should select the pertinent objective data needed to follow a specific drug therapy. Current medication can also be included.

Assessment: The pharmacist's opinion of the patient's drug therapy. By assessing the patient's therapy, the pharmacist determines what drug therapy problems exist. The assessment should be based on the data contained in the subjective and objective components of the SOAP note.

Plan: The pharmacist discusses the goals of therapy, the action that has already been taken to resolve the drug therapy problem, and any further recommendations or interventions. The pharmacist also discusses the monitoring plan and any follow-up schedule needed with the patient. The pharmacist should list the parameters that will be monitored, the intervals of measurement, and the subjective data being taken into consideration, as well as any educational interventions needed to ensure patient adherence.

Other outlines include an expanded-SOAP (adds goals, monitoring and education), HOAP (replaces subjective and objective with history and observations), SOAPIER (used by nursing: adds implementation, evaluation, revision), DAR (used by nursing: data, action, response), FARM (findings, assessment, resolution, monitoring), PWDT (pharmacist’s workup of drug therapy), PMDRP (Pharmacist’s Management of Drug-Related Problems), or the American Society of Health System Pharmacist’s PCP (pharmacist’s care plan).

Read Also: Pharmaceutical Care (PC) Competency

These various approaches all contain important elements of documentation, but they all suffer from one or more deficiencies. The original SOAP concentrates on development of a medical diagnosis using clinical information rather than drug-related problems or pharmacotherapeutic assessment. The expanded SOAP and FARM emphasize therapeutic problems, but continue to be organized around medical diagnoses. The expanded SOAP version of the case begins with the chief complaint, history of present illness, past medical history, social history, medication history, physical examination and laboratory measurements. Much of this information is not necessary because it is already in the patient’s medical record. The PWDT is a lengthy “thought process that is meant to serve as a guideline for the documentation of clinical pharmacy activities and not simply a form to be completed on each patient seen by a pharmacist.” It discusses, in a general way, the issues that should be considered when evaluating a patient database and drug therapy, but does not describe what the final write-up should actually look like. The PMDRP is even more detailed than the PWDT. The authors state that “The PMDRP can be overwhelming for pharmacists because of its detail and length.” Length is also a problem with the PCP. This method requires the pharmacist to complete at least eight pages of forms.

Read Also: Patient Focused Intervention To Enhance Medication Adherence

Detailed methods such as the PMDRP and the PCP can help inexperienced students more fully internalize aspects of the pharmaceutical care process. However, as students progress and develop a basic knowledge of therapeutic principles, these methods become cumbersome and inefficient. Eventually the student will internalize most of the concepts and will not need explicit prompting.

New Modular Format Of Pharmaceutical Care Documentation

The new format uses the following outline. In order to remember the steps in this outline one might use the following mnemonic “PH-MD-ROME.”

Patient Introduction

This lays the groundwork for what the pharmacist-patient relationship might involve. The following items would be included in this section; date of write-up, patient’s name, age (or date of birth), race, height, weight, admission date (applicable for inpatients), gender and Chief Complaint (CC) or a description of the patient’s present state. The patient’s last name may be used in the remainder of the documentation. It is also common to refer to “the patient,” or to use the patient’s initials.

Health Problems

May include a medical diagnosis, psychiatric diagnosis, patient complaint, an abnormal laboratory test result, an abnormal observation (sign or symptom), a social or financial situation, a psychological concern, or a physical limitation/disability as well as any known allergy. The pharmacist performs a physical or psychological examination or questions the patient about his or her medical history.

Medications

The present medication list can be used as a screen for drug interactions, duplication of therapy, polypharmacy, allergies, and appropriate dosage. The pharmacist should not only determine the details of the past dosage regimens but also investigate how well those regimens worked, the details of any adverse events, and why the patient is no longer taking the medications. The pharmacist should also assess patient knowledge, discover practical impediments to optimal drug utilization, and determine if there are attitudinal barriers that might have an impact on compliance.

Pharmaceutical Diagnoses

Pharmaceutical diagnosis defined as “a problem-centered, cognitive process used to identify patient-specific, drug-related problems.” A simplified version of drug related problems are;

• Not receiving an indicated drug (or device or intervention)

• Receiving the wrong drug(or device or intervention)/a more efficacious choice is possible 

• Receiving too little of the right drug

• Receiving too much of the right drug

• Experiencing an adverse drug reactions

• Experiencing a drug interaction

• Not receiving the prescribed drug

• Receiving a drug for which there is no valid medical indication.

Read Also: All About Drug Therapy Problem (DTP) In Pharmaceutical Care (PC)

After identifying the patients' drug related problems the next step would be to develop the resolutions, prioritize and then implement them. Establishing therapeutic goals required for the achievement of the desired outcome for each drug related problem identified helps in the process of resolving the drug related problems.

Recommended Orders

Recommendations usually deal with medications, but may involve non-drug therapies or another service. 

Desired Outcomes

Desired outcomes (also known as objectives or end-points) should be specific. They should state exactly what changes, or lack of changes, in the monitoring parameters would reasonably document the attainment of adequate therapeutic results, and assure that the patient was not experiencing any significant adverse drug reactions. Whereas monitoring parameters are often repeated measures.

Monitoring

Monitoring parameters are those laboratory tests, clinical measurements, and observations that are to be prospectively followed in order to provide feedback on the status of the patient’s health problems and pharmaceutical diagnosis. Each parameter should include the time when it will be obtained and by which health professional, if that is not implicitly clear.

Patient Counseling And Education

This module lists specific, unique, and important information, advice, training, and encouragement that the pharmacist will provide to the patient. The purpose of counseling is to help the patient take appropriate responsibility for the proper management of his or her illness and for recognizing and dealing with side effects of medications. If there is a diagnosis of “poor compliance,” or a diagnosis related to patient counseling, then the patient counseling module must contain directions for correcting the problems.

Summary Of Documentation

• Document an intervention with a patient 

• Document an intervention with the patient's physician 

• Document pharmaceutical care activities on a computerized or manual system