705Am J Health-Syst PharmVol 60 Apr 1, 2003

ASHP REPORTS Documenting pharmaceutical care

Purpose

The professional actions of phar-macists that are intended to ensuresafe and effective use of drugs and thatmay affect patient outcomes should bedocumented in the patient medicalrecord (PMR). These guidelines de-scribe the kinds of information phar-macists should document in the PMR,how that information should be docu-mented, methods for obtaining au-thorization for pharmacist docu-mentation, and the important role oftraining and continuous quality im-provement (CQI) in documentation.

Background

Pharmaceutical care is the direct,responsible provision of medication-related care for the purpose of achiev-ing definite outcomes that improve apatients quality of life.1 A core princi-ple of pharmaceutical care is that thepharmacist accepts professional re-sponsibility for patient outcomes.2 In-tegrating pharmaceutical care into apatients overall health care plan re-quires effective and efficient commu-nication among health care profes-sionals. As an integral member of the

ASHP Guidelines on Documenting PharmaceuticalCare in Patient Medical Records

DEVELOPED THROUGH THE ASHP COUNCIL ON PROFESSIONAL AFFAIRS AND APPROVEDBY THE ASHP BOARD OF DIRECTORS ON FEBRUARY 20, 2003

Am J Health-Syst Pharm. 2003; 60:705-7

Raymond W. Hammond, Pharm.D., BCPS, is gratefully acknowledgedfor drafting this document. The following persons are also gratefullyacknowledged for reviewing and commenting on drafts: Bill Boyce;Laurie Briceland, Pharm.D., FASHP, FCCP; Bruce Canaday,Pharm.D., BCPS, FASHP; Sian M. Carr-Lopez, Pharm.D.; Steven T.Eggleston, Pharm.D.; Brian Erstad, Pharm.D., FASHP; Wendy L.Gordon, Pharm.D.; Richard N. Herrier, Pharm.D.; Teresa J. Hudson,Pharm.D.; Anna Lau; Doug Malyuk, Pharm.D.; Paul Matuschka,Pharm.D.; Maryam R. Mohassel, Pharm.D.; Alan H. Mutnick,Pharm.D., FASHP; Bruce Nelson, M.S.; Darryl Rich, Pharm.D.,M.B.A., FASHP; Jill A. Sellers, Pharm.D.; Rita R. Shane, Pharm.D.,FASHP; Michele F. Shepherd, Pharm.D., M.S., BCPS, FASHP;

Glen T. Schumock, Pharm.D., M.B.A., BCPS; Sherry Umhoefer, M.B.A.;and Jun Yan, Pharm.D.

The bibliographic citation for this document is as follows: AmericanSociety of Health-System Pharmacists. ASHP guidelines on document-ing pharmaceutical care in patient medical records. Am J Health-SystPharm. 2003; 60:705-7.Index terms: American Society of Health-System Pharmacists; Docu-mentation; Guidelines; Pharmaceutical care; Pharmacists; Quality as-surance; Records

Copyright 2003, American Society of Health-System Pharmacists,Inc. All rights reserved. 1079-2082/03/0401-0705$06.00.

health care team, the pharmacist mustdocument the care provided. Suchdocumentation is vital to a patientscontinuity of care and demonstratesboth the accountability of the pharma-cist and the value of the pharmacistsservices. Moreover, because clinicalservices (e.g., those incident to a physi-cians services) are generally consid-ered reimbursable only when theyare necessary for the medical man-agement of a patient and when theservice provided and the patients re-sponse are carefully documented,thorough documentation may in-crease the likelihood of reimburse-ment. Early implementation of suchdocumentation practices may helphealth-system pharmacies cope withdocumentation requirements in theevent pharmacists clinical servicesbecome reimbursable.

The PMRs primary purpose is toconvey information for use in patientcare; it serves as a tool for communica-tion among health care professionals.Information in the PMR may also beused in legal proceedings (e.g., as evi-dence), education (e.g., for trainingstudents), research (e.g., for evaluating

clinical drug use), and quality assur-ance evaluations (e.g., to ascertain ad-herence to practice standards).3

Clinical recommendations madeby a pharmacist on behalf of the pa-tient, as well as actions taken in ac-cordance with these recommenda-tions, should be documented in apermanent manner that makes theinformation available to all thehealth care professionals caring forthe patient. ASHP believes that, toensure proper coordination of pa-tients medication therapies, healthcare systems must be designed to en-able, foster, and facilitate communi-cation and collaboration amonghealth care providers.2 Health caresystems must not erect barriers tothat communication or to the exer-cise of the professional judgment ofhealth care providers.

Although telephone calls and oth-er oral communication may be nec-essary for immediate interventions,they do not allow for the dissemina-tion of information to care providerswho are not a part of the conversa-tion. Such interventions should bedocumented in the PMR as soon as

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Documenting pharmaceutical careASHP REPORTS

possible after the acute situation hassettled. For less urgent and routinerecommendations, timely documen-tation is also preferred, because de-lays in response to telephone calls orpager messages may lead to miscom-municated or undocumented recom-mendations. Unofficial, temporary,or removable notes placed in thePMR do not provide a standard ofacceptable communication or docu-mentation and therefore are discour-aged. Documentation that is not apart of the PMR (e.g., documentationin pharmacy records) may provide adegree of risk reduction; however,such documentation does not pro-vide important information to othercare providers and can interruptcontinuity of care when the patient isdischarged or transferred.

Documenting pharmaceutical

care

Pharmacists should be authorizedand encouraged to make notations inthe PMR for the purpose of docu-menting their findings, assessments,conclusions, and recommendations.2

ASHP believes that all significantclinical recommendations and re-sulting actions should be document-ed in the appropriate section of thePMR. The pharmacy departmentshould establish policies and proce-dures for documenting informationin the PMR. Such policies and proce-dures will help pharmacists exercisegood judgment in determining whatinformation to document in thePMR and how to present it.

Examples of information a phar-macist may need to document in thePMR include, but are not limited to,the following:

1. A summary of the patients medica-tion history on admission, includ-ing medication allergies and theirmanifestations.

2. Oral and written consultations pro-vided to other health care profession-als regarding the patients drug thera-py selection and management.

3. Physicians oral orders received di-rectly by the pharmacist.

4. Clarification of drug orders.5. Adjustments made to drug dosage,

dosage frequency, dosage form, orroute of administration.

6. Drugs, including investigationaldrugs, administered.

7. Actual and potential drug-relatedproblems that warrant surveillance.

8. Drug therapy-monitoring findings,includinga. The therapeutic appropriateness of

the patients drug regimen, includ-ing the route and method of ad-ministration.

b. Therapeutic duplication in the pa-tients drug regimen.

c. The degree of patient compliancewith the prescribed drug regimen.

d. Actual and potential drugdrug,drugfood, druglaboratory test,and drugdisease interactions.

e. Clinical and pharmacokinetic labo-ratory data pertinent to the drugregimen.

f. Actual and potential drug toxicityand adverse effects.

g. Physical signs and clinical symp-toms relevant to the patients drugtherapy.

9. Drug-related patient education andcounseling provided.

Documentation by pharmacistsshould meet established criteria forlegibility, clarity, lack of judgmentallanguage, completeness, need for in-clusion in the PMR (versus an alter-native form of communication), ap-propriate use of a standard format(e.g., SOAP [subjective, objective, as-sessment, and plan] or TITRS [title,introduction, text, recommendation,and signature]), and how to contactthe pharmacist (e.g., a telephone orpager number).4

The authority to document phar-maceutical care in the PMR comeswith a responsibility to ensure thatpatient privacy and confidentialityare safeguarded and the communica-tion is concise and accurate. Local,state, and federal guidelines and laws

(including the Health InsurancePortability and Accountability Act of1996 [HIPAA]) and risk manage-ment sensitivities should be consid-ered. Nonjudgmental languageshould be used, with care taken toavoid words that imply blame (e.g.,error, mistake, misadventure, and in-advertent) or substandard care (e.g.,bad, defective, inadequate, inappro-priate, incorrect, insufficient, poor,problem, and unsatisfactory).3 Factsshould be documented accurately,concisely, and objectively; such doc-umentation should reflect the goalsestablished by the medical team.

Documentation of a formal consul-tation solicited by a physician or otherhealth care provider may include di-rect recommendations or suggestionsas appropriate. However, unsolicitedinformal consultations, clinical im-pressions, findings, suggestions, andrecommendations should generally bedocumented more subtly, with indi-rect recommendations presented in away that allows the provider to declinethe suggestion without incurring a lia-bility. For example, the phrase maywant to consider creates an opportu-nity for the suggestion to be actedupon or not, depending on presentingclinical factors.

Obtaining authorization to

document pharmaceutical care

The authority to document phar-maceutical care in the PMR is grant-ed by the health care organization inaccordance with organizational andmedical staff policies. Although docu-menting pharmaceutical care in thePMR is a pharmacists professional re-sponsibility, physicians and otherhealth care professionals may not beaccustomed to or open to this practice.

The following steps are recom-mended for obtaining authorizationto document pharmaceutical care inthe PMR:

1. Determine the existing organization-al and medical staff policies regard-ing authority for documentation in

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ASHP REPORTS Documenting pharmaceutical care

the PMR. These policies may providespecific guidance on how to proceed.

2. Ascertain whether other nonphysicianand nonnurse providers in the organi-zation or affiliated organizations havebeen granted authority to documentpatient care activities in the PMR. Ifso, consult them regarding the processused to establish the authority.

3. Identify physicians in the organiza-tion who are willing to support doc-umentation of pharmaceutical carein the PMR.

4. Identify the committees in the orga-nization whose recommendations ordecisions will be required to estab-lish authority for pharmacists todocument pharmaceutical care inthe PMR. Determine the necessarysequence of these approvals. Com-mittees typically involved includethe pharmacy and therapeutics(P&T) committee, the executivecommittee of the medical staff, aquality-assurance committee (e.g.,the CQI committee), and the medi-cal records committee.

5. Determine the accepted method andformat for submitting a proposal re-questing authority to documentpharmaceutical care in the PMR. Insome organizations, a written pro-posal may be required. If so, deter-mine the desired format (length,style, and necessary justification)and deadlines for proposal submis-sion. An oral presentation to the de-ciding bodies may be required. If so,determine in advance the desiredpresentation format and supportingmaterials desired by these bodies.

6. Draft a written plan describinga. Examples of information to be

documented in the PMR. It maybe helpful to describe how thisimportant information may belost or miscommunicated if it isnot documented in the PMR.

b. The locations within the PMRwhere documentation will bemade and any special format orforms proposed. New forms willhave to comply with HIPAA regu-lations and will require reviewand approval by specific organiza-

tional or medical staff commit-tees. To achieve the goal of effec-tive communication among allthe members of the health careteam, compartmentalization ofthe PMR should be avoided.

c. The persons who will be documenting pharmaceutical care inthe PMR (i.e., pharmacists, resi-dents, or students). If pharmacyresidents or students will be mak-ing notations in the PMR, proce-dures regarding authority andcosignatures will also have to bedescribed.

7. Review the draft plan with the chairof the P&T committee, the directorof nursing, the director of medicalrecords, and other appropriate ad-ministrative personnel, such as theorganizations risk management of-ficer and legal counsel.

8. Seek the endorsement and recom-mendation of the P&T committee.

9. In appropriate sequence, seek the en-dorsement or decision of any othercommittees necessary for ultimateapproval. Monitor the proposalscourse through the various commit-tees and provide assistance, clarifica-tion, or additional data as necessary.

10. When the final approving bodygrants PMR documentation authori-ty, participate in the required policydevelopment and the communica-tion of the new policy to the individ-uals or departments in the organiza-tion that will be affected by thechange (e.g., nurses, the medicalstaff, the quality-assurance staff, andthe medical records department).

Training and CQI

Pharmacist documentation in thePMR is a skill that requires ongoingtraining and evaluation.4 A temporarycommittee may be formed to managethe initial training required to imple-ment pharmacist documentation in thePMR. That committee may consider of-fering presentations by physicians orother members of the health care teamto provide their perspective on how toeffectively communicate using the PMR.The information in those presentations

may be reinforced by workshops on doc-umentation skills. Presentation andworkshop topics may include the choiceof communication method (i.e., whendocumentation in the PMR is preferredto other means of communication), thedocumentation format (e.g., SOAP orTITRS), documentation etiquette, andlegal requirements.4 Documentationskills should be demonstrated before apharmacist is allowed to make notationsin the PMR. 4 The ASHP Clinical SkillsProgram is another tool for trainingpharmacists to use the PMR.3

Documentation of pharmaceuticalcare should also be one of the manyfunctions addressed in CQI efforts.Pharmacy department CQI effortsshould include the development of qual-ity indicators that can be used to evaluatepharmacist documentation in the PMR.4

Other CQI efforts might analyze and im-prove systemwide policies and proce-dures for documenting medication use.5

Periodic review of organizational poli-cies and procedures will allow for theirrevision in response to changes inhealth care and advances in technolo-gy, including the availability of an elec-tronic PMR.6,7

References

1. Hepler CD, Strand LM. Opportunities andresponsibilities in pharmaceutical care.Am J Hosp Pharm. 1990; 47:533-43.

2. American Society of Hospital Pharma-cists. ASHP statement on pharmaceuticalcare. Am J Hosp Pharm. 1993; 50:1720-3.

3. Shepherd MF. Professional conduct anduse of patient medical records. In: ASHPClinical Skills Program, module 1: re-viewing patient medical charts. Bethesda,MD: American Society of Hospital Phar-macists; 1992:38-41.

4. Lacy CF, Saya FG, Shane RR. Quality ofpharmacists documentations in patientsmedical records. Am J Health-SystPharm. 1996; 53:2171-5.

5. Matuschka P. Improving documentationof preoperative antimicrobial prophylax-is. Am J Health-Syst Pharm. 1998; 55:993-4.

6. Lau A, Balen RM, Lam R et al. Using apersonal digital assistant to documentclinical pharmacy services in an intensivecare unit. Am J Health-Syst Pharm. 2001;58:1229-32.

7. Gordon W, Malyuk D, Taki J. Use ofhealth-record abstracting to documentpharmaceutical care activities. Can J HospPharm. 2000; 53:199-205.