Transcript Clinical Documentation July 2005

Clinical
Documentation
Pharmacy Department
Dale Tucker, RPh, BCPS
Harper University Hospital
Hutzel Women’s Hospital
Karmanos Cancer Hospital
Rehabilitation Institute of Michigan
Last Updated July 2005 with evaluation by Julie Berman (DRH), Albert Bajjoka (HVSH),
May Saba (CHM), Kim Tsilimingras (SGH), & Dale Tucker (HUH)
Goals and Objectives
Goal: To document all interventions
made by a pharmacist related to
medication usage and safety
 Objective: To apprise every pharmacist
of the system for recording all
interventions made

Summary
Why document
 Who documents
 When to document
 What to document

– Emphasis on near misses

How to document
Why Document?
Use as an indicator of medication safety
and error reduction
 Document impact of pharmacy clinical
services throughout the DMC system
 Note that appropriate transitions such
as from IV to PO medications can also
indicate a cost savings

Who Documents?
All clinical pharmacists
 All clinical pharmacy specialists
 All supervisors
 The pharmacy clinical coordinator
 All pharmacy residents
 All pharmacy students via preceptors

When to Document
A minimum of once a month at the end
of the month, or
 Can document weekly, or
 Can document daily

What to Document?
Number of new anticoagulation consults
completed
 Number of new pharmacokinetic
consults completed
 Number of 30 minute increments spent
on patient care rounds
 Number of other new consults
completed: Dofetilide, TPN, etc.

What to Document?

Number of near misses including
– Initiation of drug therapy
– Change to alternative drug
– Dosing changes
– Avoidance of a major drug interaction
– Duplication of therapy with potential toxicity
– Order clarification
– Prescriber error
What to Document?

Near misses are important
– They are any interventions which avoid a
potentially hazardous situation
– They are interventions which are used to
compare pharmacist activities between
DMC sites
– They are the targeted indicator for
pharmacist interventions and reported to
the Medication Safety Committee
What to Document?

Number of 10 minute increments spent on
chart reviews including
– General chart reviews
– Collection and assessment of daily labs or
tests
– Labs/levels ordered or discontinued
– Non-formulary changes
– IV to PO administration
– TPN changes
What to Document?



Number of days on vacation or off clinical
coverage (for clinical specialists)
Number of ADE/Dr Quality reports
completed
Number of 30 minute increments spent on
administrative duties including
– Committee work, minutes, and reports
– Documentation
– Monthly unit inspections
What to Document?


Number of 60 minute increments spent
initiating or working on research protocols
Number of 60 minutes increments spent
on education
–
–
–
–
Attending or giving lectures
Resident or student teaching
Medline/literature searches
Paperwork, grading, etc
Documentation Worksheet
Documentation Worksheet
How to Document?



From the MS Meds main menu enter
4.1.3 and hit enter
Type in “WORKLOAD” then enter
The next 7 slides indicate the
documentation procedure
Type in WORKLOAD
Then press enter
Type 1 in the ACTION field
and press enter
Enter chosen 7 digit number
to report interventions or
enter “?RX” to access choices
then press enter 4 times
Enter appropriate number
under billed doses then press
enter 3 times
Repeat the previous 2 steps
until all entries are completed
When done, “X” out of the
entry screen
Enter “A” in the action field
and press enter
How to Document?


Entries are now completed
Return to main menu
In Conclusion,
Stand up and be heard
Document often
Document regularly