Do Brazilian hospital pharmacists record, document, archive and disseminate their clinical practice?

Abstract

An exploratory study was conducted to present the approach of Brazilian hospital pharmacists to registering, documenting, archiving and disseminating clinical practice. The data were collected using an electronic questionnaire (n=348). In fact, 97.41% of pharmacists record their clinical practice, out of which 64.01% (n=217) do in electronic form, mainly in private hospitals (p<0.000), in the central, southern and southeastern regions (p=0.040), and by professionals with 1-5 years of experience (p=0.001). The main software used is non-specific to clinical practice: an electronic spreadsheet (47.93%; n=104) and text editor (13.37%; n=29). The archiving of records is performed by 87.61% (n=297) of professionals, where 80.13% (n=238) do so in physical form; however, 77.31% (n=184) of these files are kept for less than the standard recommended time. Documentation in medical records is carried out by 55.17% (n=192) of pharmacists, increasing among those with 1-5 years of clinical practice (p=0.001), and dissemination is performed by 74.71% (n=260) of hospital pharmacists, with a lower frequency in public hospitals (p=0.012) and among professionals with fewer hours dedicated exclusively to clinical pharmacy (p=0.012). These results can undergird the revision of competency-based training programs of Brazilian clinical pharmacists to remain pharmacists as a valuable health team member.

The performance of the clinical pharmacist in hospitalized patient care

“…The pharmaceutical professional, for knowing the pharmacological aspects of the drugs, is responsible for guiding the patient regarding the safe use of the medication, the possibility of adverse reactions, side effects, possible interactions and dosage. This anamnesis and, consequently, the proposed intervention, is possible through the visit to the bedside so that the professional knows the patient's profile, considering that for a better acceptance and adherence to treatment, the therapy must be adapted to the patient's lifestyle, taking into account his or her routine and restrictions (PINHO MS, et al, 2016;NÉRI EDR, et al, 2019).…”

Registro do farmacêutico hospitalar no prontuário do paciente: Ensino e prática no Brasil

“…O direito e a obrigatoriedade da documentação da prática clínica do farmacêutico são regulamentados no Brasil desde 2008 2,7,8 . Contudo, mesmo após mais de uma década de regulamentação, o registro do farmacêutico no prontuário do paciente ainda não está completamente consolidado na prática clínica 2,7,[8][9][10] .…”

Educational Tutorials on the Hospital Pharmacist's Record in the Patient's Medical Records

“…In addition, documentation is essential for assessing the overall impact of a service 3,7 . The clinical practice of recording in the patient's medical records, besides being a duty of the profession, can be seen as an effective strategy in the dissemination and maintenance of hospital pharmacists as active and valuable members of the health team [2][3][4]8 .…”