Clinical Note Writing Pharmacy Department Dale Tucker, RPh, BCPS Elizabeth Cincotta, PharmD Detroit Medical Center Last Updated July 2005 by Julie Berman (DRH), Albert Bajjoka (HVSH), May Saba (CHM), Kim Tsilimingras (SGH), & Dale Tucker (HUH)

Amount of detail may vary from site to site Goals and Objectives Goal: To orient the pharmacist to writing consistently accurate and clear notes in patient charts. Objective: To give the pharmacist experience in note writing in the chart and have the notes formally reviewed in conjunction with pharmacokinetic and anticoagulation instruction.

Amount of detail may vary from site to site Introduction Why write notes? Note variations Pharmacokinetics Anticoagulation Note types First notes Follow-up notes Note etiquette Note QAs

Amount of detail may vary from site to site Why Write Notes? Define/communicate issues Discuss current and alternative therapies Determine drug duration of therapy Suggest drug changes Inform about patient education or medication adherence history

Amount of detail may vary from site to site Types of Notes Pharmacokinetic notes Anticoagulation notes Patient education notes Renal dosing notes TPN notes Other medication notes

Amount of detail may vary from site to site General Breakdown of Notes First notes Include pertinent patient history Include reason for consult Include related lab values, vital signs, and culture results Assess medication regimen Make recommendations Follow-up notes Assess duration of therapy Update related lab values and culture results Assess medication regimen Make recommendations

Amount of detail may vary from site to site All First Notes Some sites may have a standardized sticker available Date and time Header: Pharmacy Services or Anticoagulation Dosing Service, etc. Patient demographics (age, allergy status, height, weight) and history Medications as appropriate Reason for consult or indication for therapy being monitored Pertinent lab values (BUN/Cr, CBC, cultures, etc.) Plan and/or a recommendation Signature and pager number

Amount of detail may vary from site to site Pharmacokinetic First Notes Some sites may have a standardized sticker available Include patient’s temperature (Tmax, Tcurrent) On ICU and BMT units include I/Os Include culture results Include pharmacokinetic parameters for aminoglycoside drugs Include desired goal levels and plan or need for monitoring levels Address any other antibiotics the patient is taking as per site requirements Indicate that primary team is to monitor for signs/symptoms of nephrotoxicity or ototoxicity

Amount of detail may vary from site to site Anticoagulation First Notes Some sites may have a standardized sticker available Include baseline or most recent as well as current INR/PT and/or aPTT if possible Assess potential drug and dietary interactions Include target values for INR and/or aPTT Indicate when to monitor next INR or aPTT Address all anticoagulants the patient is taking Indicate MD/RN to monitor for signs/symptoms of bleeding

Amount of detail may vary from site to site All Follow-up Notes Some sites may have a standardized sticker available Include reason for consult or indication for therapy being monitored Note: The reason for therapy may change and needs to be evaluated with each note written, i.e., rule out pneumonia is not appropriate a week after the initial note Indicate day of therapy and assess duration of therapy Include updated pertinent lab values Include a plan and/or a recommendation

Amount of detail may vary from site to site Pharmacokinetic F/U Notes Some sites may have a standardized sticker available Include patient’s temperature Update culture results Report any drug levels with an interpretation of them and/or a recommended action Indicate the times of the levels with reference to the time the dose was given On ICU and BMT units include I/Os Indicate that primary team is to monitor for signs/symptoms of nephrotoxicity or ototoxicity

Amount of detail may vary from site to site Anticoagulation F/U Notes Some sites may have a standardized sticker available Include target values for INR and/or aPTT Indicate the most recent CBC Indicate plan for transition to oral warfarin such as DC heparin when INR at goal X2 days Indicate primary team is to monitor for signs/symptoms of bleeding

Amount of detail may vary from site to site Note the Common Threads Always be organized and neat Always include reason for the consult or indication for therapy being monitored Always update any lab values or culture results Always include a plan and/or a recommendation

Amount of detail may vary from site to site “Political Correctness” Use notes to communicate information pertinent to the care of the patient Use only approved abbreviations when writing orders or notes Do not argue a point in the notes: CALL THE PHYSICIAN Avoid judgmental statements Never write a note when emotionally upset

Amount of detail may vary from site to site DMC: Unsafe Abbreviations DO NOT USEIntended MeaningUSE THIS INSTEAD U or IUunits Use “ units ” or “ international units ” µgµg micrograms Use “ mcg ” or “ micrograms ” Lack of leading zero (.5 mg) 0.5 mgAlways use leading zeros when the dose is less than a whole unit Use of trailing zero (5.0 mg) 5 mgNever use trailing zeros for doses expressed in whole numbers TIWThree times a week Use “ three times a week ” ° symbolhours Use “ hour, hr or hrs ” Q.D.Once daily Use “ daily ” Q.O.D.Every other day Use “ every other day ” MS, MSO 4, Mg SO 4 Morphine sulfate or Magnesium sulfate Use “ morphine sulfate, magnesium sulfate ”

Amount of detail may vary from site to site Word Choices Recommend When you are 100% sure of your recommendation Suggest When fairly certain of your decision Consider When you are even slightly hesitant about your recommendation

Amount of detail may vary from site to site Word Choices DON’T USE Toxic Supratherapeutic Above therapeutic range Maximum High Bad Wrong USE Above goal for this patient and indication Not within desired range for this patient

Amount of detail may vary from site to site Word Choices DON’T USE Subtherapeutic Below therapeutic range Minimum Low Bad Wrong USE Below goal for the patient and indication Not within desired range for this patient

Amount of detail may vary from site to site Word Choices DON’T USE Abbreviations for terms (drug names, pharmacokinetic parameters) that are not approved by the hospital or that may have other explanations

Amount of detail may vary from site to site Word Choices DON’T USE Exact number for an estimated value (i.e., CrCl=46ml/min) USE Ranges (i.e., CrCl=40- 60ml/min) Approximately 36ml/min Remember, calculations are an estimate!

Amount of detail may vary from site to site Clinical Quality Assessment To give a peer review of pharmacist communication in the chart and on the PMR To evaluate the content of notes To evaluate pharmacy monitoring record (PMR) for completeness To compile data quarterly as a clinical quality indicator

Amount of detail may vary from site to site Peer Reviewed Quality Assessment Everyone who writes notes Has their notes evaluated by other clinical pharmacists Is expected to evaluate and submit a QA of other clinical pharmacist’s notes (~10/month) Submits QAs of pharmacist and non-pharmacist orders when discrepancies are noted such as “U” written instead of “units” NOTE: submit QA for correct notes, too!

Amount of detail may vary from site to site QA Monitoring Form

Amount of detail may vary from site to site In Conclusion Be clear! Be accurate! Your notes are being read!