Documentation

in
Health Care Setting

Engy M Emam , PharmD

Senior Clinical Pharmacist - Nephrology Department at
AMUH and KUC
Lecturer-Practitioner, Department of Clinical Pharmacy and
Pharmacy Practice, Faculty of Pharmacy, Alexandria
university ,Pharos University
 Documentation of Pharmaceutical
Care in Patient Medical Records(PMR)
• Pharmacists should be authorized and encouraged to make notations in
the PMR for the purpose of documenting their findings, assessments,
conclusions, and recommendations.
• ASHP believes that all significant clinical recommendations and resulting
actions should be documented in the appropriate section of the PMR.
• Pharmacist documentation in the PMR is a skill that requires ongoing
training and evaluation
• Documentation skills should be demonstrated before a pharmacist is
allowed to make notations in the PMR.
 Documentation of Pharmaceutical
Care in Patient Medical Records(PMR)
• The pharmacy department should establish
policies and procedures for documenting
information in the PMR.
• Such policies and procedures will help
pharmacists exercise good judgment in
determining what information to document in
the PMR and how to present it
• It also should include the choice of
communication method(when documentation
in the PMR is preferred to other means of
communication), the documentation format
(e.g., SOAP or TITRS), documentation
etiquette, and legal requirements
 Documentation of Pharmaceutical
Care in Patient Medical Records(PMR)
Health care provider should document 3 categories of information:

I. The data used to make the decisions that fall within your scope of
responsibility

II. The decisions made for and with the patient

III. The actual outcomes that result from those decisions

 Documentation of Pharmaceutical
Care in Patient Medical Records(PMR)

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
Patient Medical
Records
(PMR)
 Documentation of Pharmaceutical
Care in Patient Medical Records(PMR)
Examples of information a pharmacist may need to document in the PMR include, but
are not limited to, the following:

1) A summary of the patient’s medication history on admission, including

medication allergies and their manifestations.

2) Oral and written consultations provided to other health care professionals

regarding the patient’s drug therapy selection and management.

3) Physicians’ oral orders received directly by the pharmacist .

 Documentation of Pharmaceutical
Care in Patient Medical Records(PMR)
Examples of information a pharmacist may need to document in the PMR include, but
are not limited to, the following:
4) Clarification of drug orders.

5) Adjustments made to drug dosage, dosage frequency, dosage form, or route

of administration.

6) Drugs, including investigational drugs, administered.

7) Actual and potential drug-related problems that warrant surveillance

 Documentation of Pharmaceutical
Care in Patient Medical Records(PMR)
8) Drug therapy-monitoring findings, including:
i. The therapeutic appropriateness of the patient’s drug regimen, including the
route and method of administration.

ii. Therapeutic duplication in the patient’s drug regimen.

iii. The degree of patient compliance with the prescribed drug regimen.

iv. Actual and potential drug–drug, drug–food, drug–laboratory test, and drug–
disease interactions.
 Documentation of Pharmaceutical
Care in Patient Medical Records(PMR)
v. Clinical and pharmacokinetic laboratory data pertinent to the drug regimen.

vi. Actual and potential drug toxicity and adverse effects.

vii. Physical signs and clinical symptoms relevant to the patient’s drug therapy.

viii. Drug-related patient education and counseling provided

ix. Physical signs and clinical symptoms relevant to the patient’s drug therapy.

9) Drug-related patient education and counseling provided

 Documentation of Pharmaceutical
Care in Patient Medical Records(PMR)
Drug–laboratory test interaction:
Urine screening for illicit drug use, which relies on immunoassay screening
For example,
i. Labetalol and ranitidine can cause a false-positive result for amphetamines
ii. Rifampin can cause a false-positive result for opioids.
Drug–disease interactions:
I. Beta-blockers used for heart failure or hypertension but worsening asthma
II. Aspirin use as antiplatelets in ACS but worsening peptic ulcers
 The documentation format
SOAP
Subjective, Objective, Assessment, Plan

FARM
Finding, Assessment, Recommendation, Monitoring

TITRS
Title, Introduction, Text, Recommendation,
Signature
 SOAP
Subjective information (S):
Defined as the information that is provided by the patient and obtained in an interview.
1) Chief Complaint (CC)
2) History of Present Illness (HPI)
3) Past Medical History (PMH) : active and resolved
4) Social History (SH):
i. Information pertaining to the patient’s health and lifestyle: diet, exercise and smoking
ii. Personal circumstances and living situation: occupation, residence and marital status
5) Family History (FH)
6) Review of Systems (ROS)
 SOAP
Objective Information (O):
Defined as the information obtained by the clinician, EMR, any lab work, and
diagnostics.
1) Medication List (medication history) : may be S or O
2) Vital Signs
3) Physical examination
4) Laboratory values
5) Diagnostics
 SOAP
Assessment (A):
This section is where the clinician assimilates all the information they have obtained from
the Subjective and Objective areas and applies it to standard practice as defined by
evidence-based medicine.
1) Prioritized problem list and drug related problems (will discussed later)
2) Assessment and therapy justification for each problem:
i. Initial Assessment
ii. Treatment goal
iii. Treatment Options and Justification (Ex : uncontrolled hypertension )
 SOAP
Plan (P):
This section is where the final treatment plan is given for each of the active problems as
justified in the assessment.
It should also be numbered and titled according to the problem list
1) Treatment plan
2) Education and Counseling
3) Monitoring, Follow-Up, and Referrals (disease progression –medications safety/efficacy)
 Assessment and Plan
Steps

1. Identify problem list (after diagnosis and taking patient history):

Medical or Pharmaceutical
II. Identify guidelines to be used
 Assessment and Plan
Steps
Medical problem

Medical history Working diagnosis

1. Infection
1. Hypertension
2. Acute kidney injury(AKI )
2. Diabetes mellitus
3. Acute coronary syndrome(ACS )
3. Heart failure
 Assessment and Plan
Steps
Pharmaceutical problems(drug-related problems)

1) Drug Selection acc. to guidelines & general condition(medication therapy not

indicated)
2) Appropriate drug dosing(acc to indications ,body weight, renal or hepatic
modifications, dosage form and route of administration)
3) Duplicate therapy
4) Appropriate preparation & method of drug administration
5) Drug precautions & contraindications
6) Drug-drug, Drug-food, Drug–laboratory test and Drug–disease interactions
7) Medication adherence(patient compliance)
8) Follow up & monitoring parameters for drug & for disease progression
 Assessment and Plan
Steps
Pharmaceutical problems (drug-related problems)
Some examples :

i. Uncontrolled Hypertension
• DRP: Combination of ACEIs and thiazide diuretics can adversely affect renal function

ii. Back Pain

• DRP: Use of scheduled naproxen can increase BP
 Assessment and Plan
Steps
Prioritized problem list and drug related problems
• This list should be complete for all ACTIVE problems for this patient and numerically
prioritized according to severity.
• Generally, the problem associated with the chief complaint will be the highest acuity;
however, this is not always the case.
• Problem titles should be very short and ARE NOT the same thing as symptoms. E.g.,
“Seasonal Allergies” (NOT itchy eyes, rhinorrhea, sneezing).
• Some problems may be controlled, but if the patient is actively on medication then it
should still be listed. These problems are listed lower in priority, and later on when
assessing the problems the documentation can state whether the current regimen is
sufficiently controlling the problem.
 Problem list
Example No. 1
Our patient’s medical history and working diagnosis
Diabetes mellitus ,uncontrolled hypertension ,Chest infection ( CAP ) and CKD
Please Prioritized this problem list

1) Chest infection ( CAP )

2) uncontrolled hypertension
3) Diabetes mellitus
4) CKD
 Problem list
Example No. 2
Our patient’s medical history and working diagnosis
Osteoporosis ,CKD,AKI and peptic ulcer
Please Prioritized this problem list

Chief complaint
1) AKI
Confusion ,anuria 2days ago ,nausea ,abdominal pain
2) Peptic ulcer
3) Osteoporosis
4) CKD
Documentation in practice
Case analysis
approach
 Case analysis approach

Age/ Complain/ Physical Lab

History Symptoms examination investigations

Diagnostic Plan of
Diagnosis Follow up
procedures management
THANK YOU