CIS Clinical Documentation Dale Tucker, RPh, M.Ed., BCPS July 26, 2006

PATIENT EDUCATION Patient has received counseling in the proper use of warfarin Complete the clinical intervention record in CIS

Pull up patient profile in CIS

Click on View and then Ad Hoc Charting

Click on Pharmacy

Click on Pharmacy Clinical Interventions

Click on Chart

All yellow boxes need to be completed

If choose Other, complete a reason why

Continue to scroll down

Complete the boxes and click on the check mark

Close the Ad Hoc Charting

A record of each intervention is found under Forms and the date and time it was done

ADVERSE DRUG EVENT Patient is on Cipro 500mg po bid (9am/5pm) and FeSO4 325mg po daily (9am) FeSO4 is rescheduled for 12 noon Complete the clinical intervention record in CIS

Pull up patient profile in CIS

Click on View and then Ad Hoc Charting

Click on Pharmacy

Click on Pharmacy Clinical Interventions then click on Chart

Make appropriate selections

Complete the boxes and click on the check mark

Close the Ad Hoc Charting

A record of each intervention is found under Forms and the date and time it was done; double click on the record to see the completed documentation