Transcript Clinical Note Writing - IHMC Public Cmaps (2)

Clinical Note Writing
Pharmacy Department
Dale Tucker, RPh, BCPS
Elizabeth Cincotta, PharmD
Detroit Medical Center
Last Updated July 2005 by Julie Berman (DRH), Albert Bajjoka (HVSH),
May Saba (CHM), Kim Tsilimingras (SGH), & Dale Tucker (HUH)
Goals and Objectives
Goal: To orient the pharmacist to writing
consistently accurate and clear notes in
patient charts.
Objective: To give the pharmacist
experience in note writing in the chart and
have the notes formally reviewed in
conjunction with pharmacokinetic and
anticoagulation instruction.
Amount of detail may vary from site to site
Introduction
Why write notes?
Note variations
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Pharmacokinetics
Anticoagulation
Note types
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First notes
Follow-up notes
Note etiquette
Note QAs
Amount of detail may vary from site to site
Why Write Notes?
Define/communicate issues
Discuss current and alternative therapies
Determine drug duration of therapy
Suggest drug changes
Inform about patient education or
medication adherence history
Amount of detail may vary from site to site
Types of Notes
Pharmacokinetic notes
Anticoagulation notes
Patient education notes
Renal dosing notes
TPN notes
Other medication notes
Amount of detail may vary from site to site
General Breakdown of Notes
First notes
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Include pertinent
patient history
Include reason for
consult
Include related lab
values, vital signs, and
culture results
Assess medication
regimen
Make
recommendations
Follow-up notes
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Assess duration of
therapy
Update related lab
values and culture
results
Assess medication
regimen
Make
recommendations
Amount of detail may vary from site to site
All First Notes
Some sites may have a standardized sticker available
Date and time
Header: Pharmacy Services or Anticoagulation Dosing
Service, etc.
Patient demographics (age, allergy status, height, weight)
and history
Medications as appropriate
Reason for consult or indication for therapy being
monitored
Pertinent lab values (BUN/Cr, CBC, cultures, etc.)
Plan and/or a recommendation
Signature and pager number
Amount of detail may vary from site to site
Pharmacokinetic First Notes
Some sites may have a standardized sticker available
Include patient’s temperature (Tmax, Tcurrent)
On ICU and BMT units include I/Os
Include culture results
Include pharmacokinetic parameters for aminoglycoside
drugs
Include desired goal levels and plan or need for monitoring
levels
Address any other antibiotics the patient is taking as per
site requirements
Indicate that primary team is to monitor for
signs/symptoms of nephrotoxicity or ototoxicity
Amount of detail may vary from site to site
Anticoagulation First Notes
Some sites may have a standardized sticker available
Include baseline or most recent as well as current
INR/PT and/or aPTT if possible
Assess potential drug and dietary interactions
Include target values for INR and/or aPTT
Indicate when to monitor next INR or aPTT
Address all anticoagulants the patient is taking
Indicate MD/RN to monitor for signs/symptoms of
bleeding
Amount of detail may vary from site to site
All Follow-up Notes
Some sites may have a standardized sticker available
Include reason for consult or indication for
therapy being monitored

Note: The reason for therapy may change and needs
to be evaluated with each note written, i.e., rule out
pneumonia is not appropriate a week after the initial
note
Indicate day of therapy and assess duration of
therapy
Include updated pertinent lab values
Include a plan and/or a recommendation
Amount of detail may vary from site to site
Pharmacokinetic F/U Notes
Some sites may have a standardized sticker available
Include patient’s temperature
Update culture results
Report any drug levels with an interpretation of
them and/or a recommended action
Indicate the times of the levels with reference to
the time the dose was given
On ICU and BMT units include I/Os
Indicate that primary team is to monitor for
signs/symptoms of nephrotoxicity or ototoxicity
Amount of detail may vary from site to site
Anticoagulation F/U Notes
Some sites may have a standardized sticker available
Include target values for INR and/or aPTT
Indicate the most recent CBC
Indicate plan for transition to oral warfarin
such as DC heparin when INR at goal X2
days
Indicate primary team is to monitor for
signs/symptoms of bleeding
Amount of detail may vary from site to site
Note the Common Threads
Always be organized and neat
Always include reason for the consult or
indication for therapy being monitored
Always update any lab values or culture
results
Always include a plan and/or a
recommendation
Amount of detail may vary from site to site
“Political Correctness”
Use notes to communicate information
pertinent to the care of the patient
Use only approved abbreviations when
writing orders or notes
Do not argue a point in the notes: CALL
THE PHYSICIAN
Avoid judgmental statements
Never write a note when emotionally upset
Amount of detail may vary from site to site
DMC: Unsafe Abbreviations
DO NOT USE
Intended Meaning
USE THIS INSTEAD
U or IU
units
Use “units” or “international units”
µg
micrograms
Use “mcg” or “micrograms”
Lack of leading zero
(.5 mg)
0.5 mg
Always use leading zeros when the
dose is less than a whole unit
Use of trailing zero
(5.0 mg)
5 mg
Never use trailing zeros for doses
expressed in whole numbers
TIW
Three times a week
Use “three times a week”
° symbol
hours
Use “hour, hr or hrs”
Q.D.
Once daily
Use “daily”
Q.O.D.
Every other day
Use “every other day”
MS, MSO4 , Mg SO4
Morphine sulfate or
Magnesium sulfate
Use “morphine sulfate, magnesium
sulfate”
Amount of detail may vary from site to site
Word Choices
Recommend
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When you are 100% sure of your
recommendation
Suggest
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When fairly certain of your decision
Consider
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When you are even slightly hesitant about
your recommendation
Amount of detail may vary from site to site
Word Choices
DON’T USE
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Toxic
Supratherapeutic
Above therapeutic
range
Maximum
High
Bad
Wrong
USE
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Above goal for this
patient and indication
Not within desired
range for this patient
Amount of detail may vary from site to site
Word Choices
DON’T USE
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Subtherapeutic
Below therapeutic
range
Minimum
Low
Bad
Wrong
USE
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Below goal for the
patient and indication
Not within desired
range for this patient
Amount of detail may vary from site to site
Word Choices
DON’T USE
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Abbreviations for
terms (drug names,
pharmacokinetic
parameters) that are not
approved by the
hospital or that may
have other
explanations
Amount of detail may vary from site to site
Word Choices
DON’T USE
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Exact number for an
estimated value
(i.e., CrCl=46ml/min)
USE
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Ranges (i.e., CrCl=4060ml/min)
Approximately
36ml/min
Remember, calculations are an estimate!
Amount of detail may vary from site to site
Clinical Quality Assessment
To give a peer review of pharmacist
communication in the chart and on the PMR
To evaluate the content of notes
To evaluate pharmacy monitoring record
(PMR) for completeness
To compile data quarterly as a clinical
quality indicator
Amount of detail may vary from site to site
Peer Reviewed Quality Assessment
Everyone who writes notes
Has their notes evaluated by other clinical
pharmacists
 Is expected to evaluate and submit a QA of
other clinical pharmacist’s notes (~10/month)
 Submits QAs of pharmacist and non-pharmacist
orders when discrepancies are noted such as
“U” written instead of “units”
 NOTE: submit QA for correct notes, too!
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Amount of detail may vary from site to site
QA Monitoring Form
Amount of detail may vary from site to site
In Conclusion
Be clear!
Be accurate!
Your notes are being read!
Amount of detail may vary from site to site