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. Such 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.
Moreover, because clinical services (e.g., those incident to a physician’s services) are generally considered reimbursable only when they are necessary for the medical management of a patient and when the service provided and the patient’s response are carefully documented, thorough documentation may increase the likelihood of reimbursement. Clinical recommendations made by a pharmacist on behalf of the patient, as well as actions taken in accordance with these recommendations, should be documented in a permanent manner that makes the information available to all the health care professionals caring for the patient.
Although telephone calls and other oral communication may be necessary for immediate interventions, they do not allow for the dissemination of information to care providers who are not a part of the conversation. Such interventions should be documented in the PMR as soon as possible after the acute situation has settled. For less urgent and routine recommendations, timely documentation is also preferred, because delays in response to telephone calls or pager messages may lead to miscommunicated or undocumented recommendations.
Unofficial, temporary, or removable notes placed in the PMR do not provide a standard of acceptable communication or documentation and therefore are discouraged. Documentation that is not a part of the PMR (e.g., documentation in pharmacy records) may provide a degree of risk reduction; however, such documentation does not provide important information to other care providers and can interrupt continuity of care when the patient is discharged or transferred.
Patient care services may require many different types of documentation, including those for the pharmacy’s internal records, billing, patient information, outcomes evaluation, and communication with other health care providers and other external entities. Several types of documentation may be associated with an MTM service, including documentation for the pharmacy’s internal records, for the patient’s records, and for communicating with other members of the health care team.
Many of these documentation elements are relevant to a variety of pharmacist-provided patient care services. When implementing a service, pharmacists should consider the various roles that documentation plays, as well as determine and establish an infrastructure and process for creating and maintaining documentation.
Documentation by pharmacists should meet established criteria for legibility, clarity, lack of judgmental language, completeness, need for inclusion in the PMR, 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. Local, state, and federal guidelines and laws (including the Health Insurance Portability and Accountability Act of 1996 [HIPAA]) and risk management sensitivities should be considered.
Non-judgmental 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 authority to document pharmaceutical care in the PMR is granted by the health care organization in accordance with organizational and medical staff policies. Although documenting pharmaceutical care in the PMR is a pharmacist’s professional responsibility, physicians and other health care professionals may not be accustomed to or open to this practice.