PHARMACEUTICAL CARE DOCUMENTATION

Ucheoma Nwizu

WHY DOCUMENT?
Evidence

of practice Dissemination of information Patient safety Continuity of care Continuous quality improvement Legal document Research

WHAT DO WE DOCUMENT?
Summary of the patients medication history at visit Drug allergies Oral and written consultations provided to other healthcare professionals Physicians oral orders received directly by the pharmacist Clarification of drug orders

WHAT WE DOCUMENT?
Adjustments
Drug

made to therapy

dosage, dosage frequency, dosage form, or route of administration investigational drugs

Drugs administered
Remember

Drug-related

problems Drug-related patient education and counseling provided

WHAT WE DOCUMENT?
Drug

therapy-monitoring findings

Therapeutic

appropriateness Therapeutic duplication Patient compliance Actual and potential drug interactions
Drugdrug,

drugfood, druglaboratory test, and drugdisease interactions

WHAT WE DOCUMENT?

Drug therapy-monitoring findings

Clinical and pharmacokinetic laboratory data Actual and potential drug toxicity and adverse Physical signs and clinical symptoms relevant to the patients drug therapy

GOOD DOCUMENTATION
Legibility Clarity
Completeness
Standard
SOAP Subjective Objective Assessment Plan

format

Language

wish to consider Completeness

may

Signature

GOOD DOCUMENTATION
Nonjudgmental

language

Avoid!!!

Words that imply blame

Error, mistake, misadventure, and inadvertent

Words

that imply substandard care

Bad, defective, inadequate, inappropriate, incorrect, insufficient, poor, problem, and unsatisfactory

GOOD DOCUMENTATION
Facts
Accurate
Concise

Objective
Must

reflect the goals established by the medical team

CONFIDENTIALITY
Rights

to privacy Confidentiality is critical in HIV patients Authorized consent

Always

verify before disclosing information

SOAP
S

Subjective

Pharmacist

impression Patients complaints about therapy

Adverse

effects Adherence challenges

SOAP
O-objective
Lab

data Patients medications

ART
Concurrent

medications OTC meditations Herbal medications

SOAP
O-Objective
Laboratory
CD4 Hb HCT Creatinine

values

Clearance

SOAP
Lab
o o

values

o o

Creatinine clearance Estimated Creatinine clearance (140 Age) (Weight in Kg) (Constant) Serum Creatinine(mol/L) For men - 1.23 For women 1.04

SOAP
Creatinine

Clearance

(140 - Age) x Wt (kg) x F (Plasma Creatinine in mg/dl) X 72

For females multiply by 0.8

SOAP
Assessment
Based
Drug

on data gathered
related problems

Sub/supra

therapeutic dosing Adverse drug reactions Wrong medication Drug interactions Treatment failure Drug addition/deletions

SOAP
P-

Plan
parameters

Monitoring
Adherence
Clinical

and laboratory data

Always

refer to previous pharmacy

notes

FINALLY
Dont

forget to sign

QUESTIONS?