Documentation in Practice Dept. of Clinical Pharmacy

Introduction Health care provider should document 3 categories of information: (a) The data used to make the decisions that fall within your scope of responsibility (b) The decisions made for and with the patient (c) The actual outcomes that result from those decisions The documentation not only must be useful to the pharmaceutical care practitioner, but needs to serve as the primary information resource for the patient, the patient's family, the patient's prescribers and other health care providers

The Electronic Therapeutic Record For medication management services Paper form is so limited nowadays It is not the same as the Electronic Medical Record (EMR) Physician practices, hospitals, and other medical institutions to keep one consistent location for all medical, administrative, and billing information related to the care of the patient It is different from prescription dispensing business Provide useful information and recommendations to physicians and others providing care for the patient

Patient's Personalized Care Plan 1.A comprehensive medication summary 2.Instruction on the proper use of each medication 3.Any additional recommendations that the practitioner provides to optimize the outcomes of the patient’s drug regimens Personal Medication Summary is organized by Medical condition, so the patient can understand that “these are the medications I use to control my diabetes Time of day, so the patient can understand “these are the medications I take in the morning and these are the medications I take at bedtime

The Electronic Therapeutic Record Medication Management Summary It needs to contain any history of patient drug allergies, adverse drug reactions, and other alerts to prevent harm to the patient The patient's electronic therapeutic record must contain all prescription medications, all nonprescription products used, any herbal, vitamin, or food supplements taken by the patient as well as why and how the patient is taking each All who provide care for the patient should be making decisions about the patient's drug therapies based on a single, universally available, electronic therapeutic record

The Electronic Therapeutic Record Management Reports Help the practitioner to keep the practice feasible and maintain its efficiency The different management reports describe various aspects of your practice including workload, activity levels, patient needs, patient types, clinical outcomes, economic impact, and quality indicator reports

Justification for the Electronic Therapeutic Record Legal liability Provide quality care to the patient Decisions and interventions Patient's condition, needs, and outcomes are constantly changing High quantity of information No one is able to remember all the vital, clinically relevant information about an individual Database for information provided to the patient Database for learning to manage your practice

The Content of the Patient's Electronic Therapeutic Record All have to be structured to support the professional practice of pharmaceutical care Three important components of practices: 1.Description of the patient care process 2.Description of the cognitive activities involved in the process (pharmacotherapy workup) 3.Description of what is documented as a result of the process

An Integration of the Patient Care Process, the Cognitive Process, and the Documentation Process

The information generated in the Patient's Electronic Therapeutic Record must be shared with the patients’ other care providers. Interfacing with the EMR Generate reports that can be sent to the EMR

The Patient's Personalized Care Plan Its important because: Provides the patient with a summary of all of his drug, disease, and personal health information at all times. This information can be shared at all physician visits, dental visits, when the patient is on vacation and needs information, and if an emergency arises. Provides the patient a place to record questions, observations, or findings related to drug therapy outcomes, so the patient can discuss them with the pharmacist, physician, or other health Empowers the patient to become and stay actively involved in drug therapy decisions

Personalized Pharmaceutical Care Plan

Medication-Related Needs Personalized Care Plan should also include a section on the Medication Related Needs It describes any unique patient needs or preferences that might influence drug therapy (ex: medication allergies, adverse reactions and Information describing patient preferences) Personalized Care Plan do not only refer to the offending drug, but also include special instructions such as: allergic to penicillin and should avoid penicillin and related antibiotics such as amoxicillin, Amoxil, ampicillin, and Augmentin

Summary of All of Your Medications The personalized care plan summarizes for the patient all of the medications she or he is taking and the medical conditions being treated or prevented This section connects four pieces of information for the patient: Indication or medical condition Medication Directions Prescriber or pharmacist who recommended the medication If a patient is taking two of three medications for the same indication, all three are organized and related to the single indication All the information should be clearly stated Medications can be listed as generic, trade-name, or both, whichever is most helpful to the patient

Personalized Care Plan. Description and/or illustration of the tablet or capsule is often useful for the patient The directions for use should represent how the patient is actually going to take the medication Personalized care plan translates/interprets complex and often confusing directions into meaningful, comprehensible language and communicates a realistic attainable set of goals and directions to patients list of medications no longer been taken.

Information for Each of the Medications and Instructions Personalized care plan not only contains the summarized information, but also contains more Details information about each medical condition (common terminology, signs and symptoms, causes, and common approaches to treatment) Health advice Medication, specific, detailed instructions Medication are the common side effects A key section of the Personalized Care Plan is the description of the Follow-up Checkpoints

Simple list of drugs vs the personalized care plan (PCP) PCP serves as a summary record of what the patient has agreed to undertake as personal responsibility for the care process (How to Take the Medication), what should happen (Goals of Therapy and Follow- up check points), and what might happen (Common Side Effects) New Concerns/Questions/Expectations Personalized Care Plan also includes a very important section to be used by patients to record concerns, questions, or other important issues that they want to discuss with the pharmacist or physician during their next visit

Finally, the Personalized Care Plan is signed by the pharmacist who prepared it for the patient, and dated in order to ensure that this individual can understand the content and its implications

Physician Reports Electronic therapeutic record must also serve to effectively communicate with the patient's other care providers The central portion of the physician report is the display of ALL of the patient's medications arranged by medical condition.

Management Reports Electronic therapeutic record data could be used to evaluate the quality of the service and assist practitioners to improve care Management reports will focus on such issues as How many patients are seen daily? How long do practitioners spend, on average, with patients? What types of problems are most common in the practice? What types of resources are most frequently required for patient care? Management Reports can be used to determine which services are most effective and should be continued, and which are less valuable and should be modified or discontinued

Software Programs for the Documentation of Medication Management Services

Guidelines for Documenting Pharmaceutical Care Be timely Be precise Be concise Be complete

Summary All patient care that is provided as medication management services must be documented to meet ethical, professional, and legal guidelines and standards. The patient's Electronic Therapeutic Record is the basis for record-keeping for medication management services. The Patient's Personalized Care Plan contains the information that is most useful to the patient and having this information allows the patient to actively participate in his care. The Electronic Therapeutic Record provides physicians and other practitioners with unique, comprehensive, and useful information about all of the patient's medications, drug therapy problems, and recommendations to optimize the patient's medications.

Summary The documentation of medication management services generates the data you will need to manage, expand, improve, and justify your service. Governmental guidelines will require documentation systems used by pharmaceutical care practitioners to (a) meet meaningful use criteria, (b) communicate with other patient care systems, and (c) generate research data to improve patient care and population health in the future. If you didn't document it, you didn't do it!