In this four-part series, the College focuses on each domain of the community pharmacist practice assessment, highlighting trends that are being seen in practice. Part Three focuses on documentation. Review: Part One (Patient Assessments) in the Spring 2018 edition and Part Two (Decision Making) in the Summer 2018 edition.
STANDARD OF PRACTICE
Documentation is a fundamental cornerstone of a pharmacy professional’s responsibilities and is a standard of practice. Appropriate documentation has four important characteristics: it is factual, it is complete, it is current (timely) and it is organized.
Patient documentation has significantly evolved beyond the use of a check mark to indicate that a patient or their agent was counselled. Information obtained from thorough patient assessments and the rationale behind thoughtful, patient-focused decisions has short-lived benefits if it is not recorded and accessible to pharmacy team members and other health care professionals for continuity of patient care. Thus, the adage “If it wasn’t documented, it wasn’t done” is highly relevant to pharmacy practice.
Today, pharmacy professionals are not only expected to gather the information needed to assess the patient and the prescription, they must also keep a reliable and easily-retrieved record of this information. Documentation of what is clinically relevant is vital to continuity of patient care. While changes to a patient’s health or characteristics are likely to be noted, things that have not changed may also be of significance.
Documentation on the patient record doesn’t require noting entire conversations with patients or their agents. It’s about using professional judgement to identify key pieces of information necessary to support decision making. A good documentation practice suggested by practice advisors is to anticipate and record what a colleague would need to know about a patient’s existing condition at a future time in order to continue where you left off. For example, if you addressed a concern, explain your course of action and the rationale behind it.
Effective documentation should incorporate pertinent patient information and relevant data acquired from prescribers and other healthcare providers. In turn, it will optimize decision-making, help avoid errors, reduce duplication of services and demonstrate one’s thought process. Documentation includes any written or electronically-generated information about a patient that describes the care or services provided. It should include evidence of the objective and/or subjective data used for clinical decision making.
Designated managers are encouraged to emphasize consistency in documentation approaches within a pharmacy by establishing operational processes for documenting on the patient record. The practice of writing notes on a slip of paper or notebook where it can be forgotten or misplaced is discouraged by practice advisors who stress the importance of directly recording information into the patient record.
The past two issues of the practice assessment series featured the following patient scenario to reinforce learning: A 59-year-old male has been filling his prescriptions at the pharmacy for about one year. His patient profile shows that he has Type 2 Diabetes, dyslipidemia, osteoarthritis and is a smoker. He fills his medications mostly on time, doesn’t say much when picking up his medications and you haven’t noticed any changes on his prescriptions profile. He’s currently on Atorvastatin 10mg once daily, Metformin 1000mg twice daily, Gliclazide MR 30mg daily and Venlafaxine 150mg once daily and was looking to pick up his new refills.
During his latest visit to the pharmacy, the pharmacist on duty followed up on a note from a colleague to check in with his progress on quitting smoking. The decision was made to initiate smoking cessation treatment, as well as to continue self-monitoring his daily blood glucose levels. In response to the pharmacist’s recommendation to adjust the dose of his diabetes medication, a reply from the doctor on file indicates that the patient was overdue for his bloodwork (A1C and cholesterol lab tests) and changes would be considered pending the results.
OCP’s DOCUMENTATION GUIDELINES
A member uses professional judgment in determining the extent of documentation and information that should be contained in the patient record. Members should avoid extraneous information and only document what is clinically relevant. The meaning of any entry into a patient record should be clear to a health care professional reading the record. The level of detail will vary depending on each situation, including when necessary:
- Identifying information, including that of the member documenting the patient contact;
- Patient presenting symptoms or concerns (e.g. medication assessment, pharmaceutical opinion, follow-up, etc.);
- Patient history summary and care plan if developed. (The record should acknowledge whether a care plan was available. If a care plan is part of the patient record it should be acknowledged in the documentation);
- Documentation of patient’s voluntary and informed or implied consent, or that of their substitute decision maker, if any;
- Information provided to or received from other caregivers;
- Collaboration undertaken with other caregivers, including outcomes, and/or proposed courses of action;
- Assessments, interventions, and recommendations where professional judgment was exercised along with the evidence on which the recommendations are based; and
- A follow-up plan that is sufficiently detailed to monitor the patient’s progress and ensure continuity of care by the pharmacist, and other regulated health professionals or caregivers, if applicable.
The patient has returned to the pharmacy after his doctor’s visit and presents a new prescription. Upon reviewing his profile, you verify that the dose of his atorvastatin has been increased and the others remained unchanged. The patient explains that the doctor was mostly concerned about his “bad” cholesterol and only wanted to make one medication change at a time, with a follow-up appointment in four weeks. He has also brought a copy of the lab results, which you review and offer to include in his patient profile.
When you commend his decision to quit smoking, the patient admits that, after setting a quit date, he was still struggling to go more than a day or two without any nicotine. However, he says the effort continues to get easier and he is proud of his progress even though he couldn’t quit “cold-turkey.” To keep him motivated and compliant, you decide to quickly review his cardiovascular disease (CVD) risk, asking for his blood pressure as measured at the doctor’s visit to emphasize his ability to control some of his “modifiable” risk factors.
The Chat, Check, Chart DAP model used by the pharmacy team guides the format of your documentation on the patient’s profile:
Data – What information did you gather and check? (Lab test results, new dose of atorvastatin, patients reported BP, smoking status, date of next visit)
Assessment – What is your assessment of the patient and therapy? (Increase in dose is clinically appropriate based on patient’s risk factors for CVD and lab results)
Plan – What steps did you/will you take? (Patient to monitor for side effects of atorvastatin, what to do if myalgia occurs)
After ensuring the key points from today’s visit are entered into the pharmacy’s software system, you save the record which correlates to your name and is timestamped. The pharmacy assistant performs the administrative task of scanning in the lab results, following the procedure established for naming documents to ensure easy identification and retrieval in the future.
As a pharmacy professional, you play an essential role in the circle of patient care. Effective documentation maintains the standards of the profession and contributes to optimized health outcomes.
RESOURCES RELATED TO DECISION MAKING
- Chat, Check, and Chart – This resource provided by the Alberta College of Pharmacists is focused on getting patient information, evaluating the appropriateness of therapy and documentation.
- The Four R’s of Documentation – Reliable, Retrievable and Useable, Robust and Retained – is another highly effective way to ensure successful patient recordkeeping procedures.
- Documentation Guidelines
- Documentation Practice Tool
- Pharmacy Practice Assessment Criteria - Documentation
- Documenting Pharmacy Interventions in a Busy Dispensary –Produced by the Canadian Pharmacists Association, webinar material focuses on reasons for/benefits of documentation.