1. The first screen used is designed to document symptom pursuit and review the complications of anticoagulation therapy. In addition this screen is where alcohol use, diet, and current dosing of anticoagulation therapy should be noted.
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2. The next step within the EMR is linking the reason for the office visit with any lab orders that will be performed in the office (i.e., INR). This screen shows the link of diagnosis with lab test(s) needed and allows the pharmacist to order this test; it will be shown in the objective section of the note.
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3. This is the results screen where the INR is listed so it will appear in the final electronic note.
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4. This assessment screen outlines the visit and what was done
This assessment screen outlines the visit and what was done. The pharmacist can also document data reviewed and education regarding that result. Also note the time element at the bottom of the screen; this assists with billing.
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5. Documentation of medication reconciliation with each visit is mandatory, and any oversights are corrected and an electronic medication list is updated. This is then printed for the patient and given to him or her in the process of scheduling a follow-up appointment for the patient’s next INR check.
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6. This screen documents the next step in therapy based on the INR result
This screen documents the next step in therapy based on the INR result. If therapeutic, the pharmacist can continue current dose with a follow-up timeline documented. Also note the text boxes do expand and allow for more information if the pharmacist would like to add a full plan outline in the system for complicated patient plans. The resulted INR is also documented here as well as in the objective section so the physician will have multiple opportunities to see the results before the sign off on the electronic note.
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7. This screen is where the pharmacist can review and document patient education regarding anticoagulation therapy and shows that risk versus benefits were discussed with the patient. Also note that this education page includes other links; if one of those were clicked, then there would be questions on the next screen relating to patient education for that topic/disease state.
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8. This screen is where the pharmacist can review and document patient education regarding anticoagulation therapy and shows that risk versus benefits were discussed with the patient. Also note that this education page includes other links; if one of those were clicked, then there would be questions on the next screen relating to patient education for that topic/disease state.
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9. This screen allows for documentation of the patient’s understanding of the information being provided by the pharmacist. Text boxes can be used for the pharmacist to elaborate on the level of comprehension of the patient and could also be used to document literacy level, how the patient learns, and reinforcement that may be needed.
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10. This screen shows the follow-up plan documentation --- when the patient needs to schedule his or her next pharmacy appointment and also a referral text box to document the pharmacist asking the patient to see other health care professionals. This could range from the patient’s PCP to a specialist such as cardiology for clarification of treatment duration.
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11. For those who teach and have rotators seeing patients, this allows for the pharmacy resident to see this patient and create a visit note. Then the preceptor can sign off on the note with any addendum that is needed. Resident documentation is specific for each institution, thus this screen can be used to suit the needs of the pharmacist in charge. For many, this screen is used to show that the visit was performed by a resident with assistance from the preceptor. For others, this screen allows for a final check before they sign the note and send it to the referring physician for final approval of the plan.
Copyright McKesson Corporation and/or one of its affiliates. Used with permission. All rights reserved.