Pharmacists' documentation in patients' hospital health records: issues and educational implications

Abstract

Objectives We aimed to identify potential barriers to hospital pharmacists' documentation in patients' hospital health records, and to explore pharmacists' training needs. Our objectives were to identify the methods used by pharmacists to communicate and document patient care issues, to explore pharmacists' attitudes towards documentation of patient care issues in health records, to identify and examine the factors influencing whether or not pharmacists document their care in health records and to make recommendations to inform development of a training programme to educate pharmacists regarding documentation in health records. Methods Methods included a questionnaire and focus groups. The study poulation was 40 clinical pharmacists in a 900-bed London teaching hospital. Key findings Thirty-nine pharmacists completed the questionnaire and 32 attended a focus group. Questionnaire responses indicated that 29 (74%) pharmacists did not write in patient health records; most preferred temporary notes. However, most respondents agreed that documenting their input in the health record was important. Few pharmacists believed that writing in health records would affect the doctor-pharmacist or patientdoctor relationship, or felt that health-record availability or time were barriers. Most knew when, how and which issues to document; however, most wanted more training. Focus-group discussions revealed that pharmacists feared litigation and criticism from doctors when writing in health records. Pharmacists' written communication in health records was also influenced by the perceived significance and appropriateness of clinical issues, pharmacists' acceptance by doctors, and pharmacists' 'ownership' of the health record.Conclusions While recognising the importance of documenting relevant issues in health records, pharmacists rarely did so in practice and preferred to use oral communication or temporary adhesive notes instead. Pharmacists need to overcome their fear of criticism and litigation in order to document more appropriately in health records. A trust policy and training may offer pharmacists a sense of protection, enabling more confident documentation in patients' health records.

Impact of the Collaborative Pharmaceutical Care at Tallaght Hospital (PACT) model on medication appropriateness of older patients

“…Importantly, the identified standard care acceptance rate is similar to other Irish studies where a ward-based clinical pharmacy service was also employed 21 22. Reasons for this may include an absence of doctor recognition of the pharmacist's contribution, as previously described in a London hospital, or inferior collaboration and teamwork in ward-based standard care 44. The model of clinical pharmacy service currently provided in the majority of Irish teaching hospitals involves medicines reconciliation at admission 45.…”

Collaborative pharmaceutical care in an Irish hospital: uncontrolled before-after study

“…The lower frequency of, and delay in, standard care clinical pharmacist's recommendation acceptance demonstrates an inefficiency in standard care. Possible contributing factors include an absence of physician recognition of the pharmacist's contribution, as previously described in a London hospital,61 or inferior collaboration and teamwork in the ward-based model. However, this is countered by the estimation that PACT pharmacists were able to see approximately 70% the volume of patients as the standard service, meaning that PACT is 40% more intensive in terms of clinical pharmacy resource.…”

Evaluation of a semi-structured model for the medication therapy management record in the hospital setting

“…The recording of the clinical activities of the pharmacist must compose his routine in any setting and with any service offered. Research studies carried out on the subject found results that reinforce the importance of this practice and describe advantages such as patient safety, promoting the rational use of medicines and providing resources for patient care 22,23 .…”

“…In this context, Pullinger & Franklin 22 pointed out that most studies on the documentation of the multidisciplinary team in hospitals did not find records of pharmacists and, of those that were performed, most did not include all information from pharmaceutical care. In addition, even when they knew what, when and how to register in the medical record, most of them presented the need to receive training, as those who were trained, demonstrated accuracy and quality in the documentation.…”