Clinical Documentation Pharmacy Department Dale Tucker, RPh, BCPS Harper University Hospital Hutzel Women’s Hospital Karmanos Cancer Hospital Rehabilitation Institute of Michigan Last Updated July 2005 with evaluation by Julie Berman (DRH), Albert Bajjoka (HVSH), May Saba (CHM), Kim Tsilimingras (SGH), & Dale Tucker (HUH)

Goals and Objectives Goal: To document all interventions made by a pharmacist related to medication usage and safety Objective: To apprise every pharmacist of the system for recording all interventions made

Summary Why document Who documents When to document What to document –Emphasis on near misses How to document

Why Document? Use as an indicator of medication safety and error reduction Document impact of pharmacy clinical services throughout the DMC system Note that appropriate transitions such as from IV to PO medications can also indicate a cost savings

Who Documents? All clinical pharmacists All clinical pharmacy specialists All supervisors The pharmacy clinical coordinator All pharmacy residents All pharmacy students via preceptors

When to Document A minimum of once a month at the end of the month, or Can document weekly, or Can document daily

What to Document? Number of new anticoagulation consults completed Number of new pharmacokinetic consults completed Number of 30 minute increments spent on patient care rounds Number of other new consults completed: Dofetilide, TPN, etc.

What to Document? Number of near misses including –Initiation of drug therapy –Change to alternative drug –Dosing changes –Avoidance of a major drug interaction –Duplication of therapy with potential toxicity –Order clarification –Prescriber error

What to Document? Near misses are important –They are any interventions which avoid a potentially hazardous situation –They are interventions which are used to compare pharmacist activities between DMC sites –They are the targeted indicator for pharmacist interventions and reported to the Medication Safety Committee

What to Document? Number of 10 minute increments spent on chart reviews including –General chart reviews –Collection and assessment of daily labs or tests –Labs/levels ordered or discontinued –Non-formulary changes –IV to PO administration –TPN changes

What to Document? Number of days on vacation or off clinical coverage (for clinical specialists) Number of ADE/Dr Quality reports completed Number of 30 minute increments spent on administrative duties including –Committee work, minutes, and reports –Documentation –Monthly unit inspections

What to Document? Number of 60 minute increments spent initiating or working on research protocols Number of 60 minutes increments spent on education –Attending or giving lectures –Resident or student teaching –Medline/literature searches –Paperwork, grading, etc

Documentation Worksheet

How to Document? From the MS Meds main menu enter and hit enter Type in “WORKLOAD” then enter The next 7 slides indicate the documentation procedure

Type in WORKLOAD Then press enter

Type 1 in the ACTION field and press enter

Enter chosen 7 digit number to report interventions or enter “?RX” to access choices then press enter 4 times

Enter appropriate number under billed doses then press enter 3 times

Repeat the previous 2 steps until all entries are completed

When done, “X” out of the entry screen

Enter “A” in the action field and press enter

How to Document? Entries are now completed Return to main menu

In Conclusion, Stand up and be heard Document often Document regularly