1. Documentation of Care Provided Patient’s care - who should do it? WHY DOCUMENT? When should it occur? Where should it be documented? How should it be documented? What should be documented?

2. Documentation of Care Provided Issues to consider - comfort level - time it takes - restrictions at site (where, what, who) - need to use it! (for follow-ups) - responsibility - signing off a patient

3. Format of Documentation S O A P format pharmaceutical care format comprehensive vs. specific pre-formatted form for site pharmacy records vs. medical chart

4. Format of Documentation Pharmaceutical Care Format –many ways of doing this –may depend on pharmacist and site

5. An Example of Documentation Pharmaceutical Care Format Drug-related issue/concern/problem Justification Recommendation Plan

6. An Example of Documentation If a letter to a physician to change therapy, may include the following: Drug-related issue/concern/problem Justification Recommendation

7. What should be documented? Any information pertaining to drug therapy of the patient (real or potential) Should include patient, drug, or disease information that confirm the validity of the DRP Should succinctly state the specific recommendation(s) for changes in drug selection, dosage, duration, route

8. What should be documented? Recommendations for monitoring of the response to drug therapy including the tests, frequency, interpretation of test Activities and follow-up to be conducted by pharmacist

9. What not to include in the documentation? Suggestions to change or monitor therapy without providing specific individualized parameters not useful (e.g. check INR?) Unrealistic recommendations? (option not available at site?) Unknown abbreviations Trade names for single products?

10. What not to include in the documentation? Health care record is a legal document Must accurately reflect care provided –Do not add information at a later date –Do not add to someone else’s note

11. Documentation… SOAP note – what to include under each sub-heading (used by most health professionals) Example of a Clinical Pharmacist’s Note

12. Documentation… Pharmaceutical care based upon a thorough review of systems; however, only include info. pertinent to the therapeutic issue being discussed

13. Documentation… Exam purposes: –Chart Documentation SOAP format Pharmaceutical Care format Ensure that all relevant issue for the discussion of the therapeutic issue is included.