Documentation of Care Provided Patients care who should

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Documentation of Care Provided • • • Patient’s care - who should do it?

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?

Documentation of Care Provided • Issues to consider - comfort level - time it

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

Format of Documentation • • • S O A P format pharmaceutical care format

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

Format of Documentation • Pharmaceutical Care Format – many ways of doing this –

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

An Example of Documentation Pharmaceutical Care Format Drug-related issue/concern/problem Justification Recommendation Plan

An Example of Documentation Pharmaceutical Care Format Drug-related issue/concern/problem Justification Recommendation Plan

An Example of Documentation If a letter to a physician to change therapy, may

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

What should be documented? • Any information pertaining to drug therapy of the patient

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

What should be documented? • Recommendations for monitoring of the response to drug therapy

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

What not to include in the documentation? • Suggestions to change or monitor therapy

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?

What not to include in the documentation? • Health care record is a legal

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

Documentation… • SOAP note – what to include under each sub-heading (used by most

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

Documentation… • Pharmaceutical care based upon a thorough review of systems; however, only include

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

Documentation… • Exam purposes: – Chart Documentation • SOAP format • Pharmaceutical Care format

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