Development of a Documentation Rubric and Assessment of Pharmacists’ Competency for Documentation in the Patient Health Record

Abstract

<p><strong>ABSTRACT</strong></p><p><strong>Background: </strong>Documentation of information in the health record by pharmacists is vital to patient care. Failure to document, or failure to document appropriately, may have negative effects on patients.</p><p><strong>Objectives: </strong>The primary objective was to determine pharmacists’ competency in 18 elements of chart note documentation at 2 tertiary care centres and 1 rehabilitation centre. The secondary objectives were to quantify the number of episodes of documentation by pharmacists, to characterize the clinical activities associated with this documentation, and to determine whether there were differences in level of competency according to years of hospital experience, additional clinical training, and note type.</p><p><strong>Methods: </strong>This study used prospective audit methodology. Notes documented during a 6-week study period (February to April 2015) were assessed using a rubric specifically created to evaluate 18 of the essential elements of documentation, as defined by the Canadian Society of Hospital Pharmacists. Four of the elements of chart note documentation were assessed on a yes/no basis, and Bloom’s taxonomy was used to define the level of competency for the other 14 elements. Values were assigned to each level and were then used to calculate mean scores.</p><p><strong>Results: </strong>A total of 115 pharmacist notes, created by 29 of the 35 pharmacists included in the study, were assessed. The mean competency score per pharmacist was 2.2 (standard deviation [SD] 0.3; maximum score 3). Elements of documentation with the highest level of competency were diplomatic tone, conciseness, and clarity; elements with the lowest level of competency were medication list, note title, monitoring, and drugrelated problem statements. The most frequent note types concerned drug-related problems (50 [43%]), pharmacokinetics (25 [22%]), and patient education (19 [17%]). Levels of competency were highest for notes related to patient education (mean 2.4, SD 0.2) and lowest for notes concerning drug-related problems (mean 2.1, SD 0.3) and notes providing clarification (mean 2.1, SD 0.3). The level of competency was not significantly affected by additional clinical training or years of hospital experience.</p><p><strong>Conclusions: </strong>Pharmacists in this study documented concisely, clearly, and in a diplomatic tone; however, there was room for improvement in the frequency and elements of chart note documentation in the patient health record.</p><p><strong>RÉSUMÉ</strong></p><p><strong>Contexte : </strong>La consignation d’information par les pharmaciens dans les dossiers de santé est essentielle aux soins des patients. Négliger de consigner l’information ou le faire inadéquatement peut avoir des effets négatifs pour les patients.</p><p><strong>Objectifs : </strong>L’objectif principal était de déterminer le niveau de compétence des pharmaciens en ce qui concerne 18 éléments de consignation aux dossiers médicaux de patients dans deux établissements de soins tertiaires et dans un établissement de réadaptation. Les objectifs secondaires étaient de quantifier le nombre de cas de consignation par les pharmaciens, d’offrir un portrait des activités cliniques associées à cette prise de notes et de déterminer s’il y avait des différences quant au niveau de compétence selon le nombre d’années d’expérience en hôpital, la formation clinique supplémentaire et le type de notes.</p><p><strong>Méthodes : </strong>La présente étude a employé l’audit prospectif comme méthodologie. Les notes consignées durant une période de 6 semaines (de février à avril 2015) ont été jugées à l’aide d’une grille conçue spécialement pour évaluer 18 des éléments essentiels de la prise de notes tels qu’ils sont définis par la Société canadienne des pharmaciens d’hôpitaux. Une évaluation dichotomique (soit oui soit non) a été utilisée pour quatre des éléments de la prise de notes et la taxonomie de Bloom a servi à définir le niveau de compétence pour les 14 autres éléments. Des valeurs ont été attribuées à chaque niveau et ont ensuite été utilisées pour calculer les scores moyens.</p><p><strong>Résultats : </strong>Au total, 115 notes rédigées par 29 des 35 pharmaciens vises par l’étude ont été analysées. Le score moyen de compétence par pharmacien était de 2,2 (écart-type de 0,3; score maximum de 3). Les éléments de la prise de notes présentant le niveau de compétence le plus élevé étaient : le ton diplomatique, la concision et la clarté. Les éléments affichant le plus bas niveau de compétence étaient : la liste des médicaments, le titre de la note, le suivi et l’énonciation des problèmes liés à la pharmacothérapie. Les types de notes les plus fréquents traitaient : de problèmes liés à la pharmacothérapie (50 [43 %]), de la pharmacocinétique (25 [22 %]) et des conseils aux patients (19 [17 %]). Les niveaux de compétence étaient plus élevés pour les notes à propos des conseils aux patients (moyenne de 2,4, écart-type de 0,2) et les niveaux étaient plus faibles pour les notes concernant les problèmes liés à la pharmacothérapie (moyenne de 2,1, écart-type de 0,3) et celles fournissant un éclaircissement (moyenne de 2,1, écart-type de 0.3). Le niveau de compétence n’était pas significativement influencé par une formation clinique supplémentaire ou les années d’expérience en hôpital.</p><p><strong>Conclusion : </strong>Les pharmaciens évalués dans la présente étude consignaient leurs notes de façon concise et claire sur un ton diplomatique. Par contre, il y avait lieu d’améliorer la fréquence et les éléments des notes consignées dans les dossiers médicaux des patients.</p>

Construção De Um Modelo De Evolução Farmacêutica Em Prontuário Médico

“…A parte final do método SOAP é o plano de cuidados e condutas, onde devem ser descritas as informações relevantes para que as metas terapêuticas sejam cumpridas, bem como pontos para resolução que envolvam os PRM, e os parâmetros clínicos e laboratoriais que devem ser monitorados na determinação da necessidade, efetividade e segurança da farmacoterapia do paciente. Além disso, ações de educação em saúde para o uso correto de medicamentos e, se necessária, a data para rea-10.14450/2318-9312.v31.e2.a2019.pp129-134 valiação (18,19). Nesse ponto, também devem ser registradas as recomendações farmacêuticas (RF), visto que a RF é caracterizada como o ato planejado, documentado e realizado junto ao usuário e/aos profissionais de saúde, e que compõe o processo de acompanhamento farmacoterapêutico (4,11).…”

Construção De Um Modelo De Evolução Farmacêutica Em Prontuário Médico

“…Deve seja avaliado, pelo Farmacêutico Clínico, o uso adequado dos protocolos institucionais de profilaxias que envolvam medicamentos, como o protocolo de profilaxia de úlcera de estresse, no qual a avaliação, pelo farmacêutico, tem sido associada à diminuição do uso inapropriado de medicamentos por pacientes que não tinham ou deixaram de ter critérios para profilaxia medicamentosa, bem como à redução de custos associados ao uso desnecessário de medicamentos (17 A parte final do método SOAP é o plano de cuidados e condutas, onde devem ser descritas as informações relevantes para que as metas terapêuticas sejam cumpridas, bem como pontos para resolução que envolvam os PRM, e os parâmetros clínicos e laboratoriais que devem ser monitorados na determinação da necessidade, efetividade e segurança da farmacoterapia do paciente. Além disso, ações de educação em saúde para o uso correto de medicamentos e, se necessária, a data para rea- valiação (18,19). Nesse ponto, também devem ser registradas as recomendações farmacêuticas (RF), visto que a RF é caracterizada como o ato planejado, documentado e realizado junto ao usuário e/aos profissionais de saúde, e que compõe o processo de acompanhamento farmacoterapêutico (4, 11).…”

Clinical Pharmacy Activities Documented (ClinPhADoc): Development, Reliability and Acceptability of a Documentation Tool for Community Pharmacists

“…As part of the quality control initiatives established by the Swiss Pharmacists Association (pharmaSuisse) and health insurance, mystery shopping tests and administrative checks must be conducted for pharmacy clinical activities to be paid. Therefore, documentation of clinical activities may be helpful to demonstrate the value of the pharmacist's services [6]. However, to be accountable, documentation of pharmacists' clinical activities should meet established criteria for legibility, clarity, and completeness [9].…”

“…The management of DRPs involves different clinical activities, mainly determined by the setting (hospital or community pharmacy). Likewise, the documentation of such activities is performed differently depending on the setting [6]. It has been recommended that pharmacists document any professional activities that are intended to ensure the safe and effective use of drugs and that may affect patient outcomes [7].…”

“…It has been recommended that pharmacists document any professional activities that are intended to ensure the safe and effective use of drugs and that may affect patient outcomes [7]. However, documentation of clinical activities still remains a challenge [6], particularly in community pharmacies [8].…”