January/February 2004 - Ontario College of Pharmacists

PRINCIPLES OF DOCUMENTATION
Identifying a patient problem or need and determining or anticipating appropriate outcomes are the
foundation of documentation.
The following questions form the basic principles related to documentation. These are also based on the
expectation that anyone reading a documented record should be able to easily and clearly determine:
• What happened?
• To whom did it happen?
• Who made it happen or what caused the event?
• When did it happen?
• Where did it happen?
• Why did it happen?
• What was the outcome of the actions that were taken?
While the level of detail necessary for documenting will vary depending on each situation, it is not always
necessary to apply all the principles, all the time. Pharmacists should keep documentation concise by only
documenting what is important and avoiding extraneous information.
WHAT SHOULD I DOCUMENT?
There are many opportunities in the course of your
daily practice where documentation is beneficial
(discussions with other health care professionals,
agents, financial institutions, third parties, suppliers, etc.).
Although the Guidelines for Documentation can be used at
any time, the College is starting its focus on two general
categories: a) Patient Specific and b) Prescription Specific.
1. Patient Specific*
a) Actual or potential drug related problems arising
from both prescription and non-prescription
medications
*Operational Components 1.2, 1.5, and 1.7, of the Standards
of Practice 2003 identify the expectations for
documentation by pharmacists.
Scenario 1:
A pharmacist received a new prescription for a young
woman for Wellbutrin® 150 mg., M: 90, Sig: iii tabs daily.
When the pharmacist dialogued with the patient, the
patient explained that she has been taking three tablets
every morning for several months, from another pharmacy.
Since the patient was going to return to pick up the
prescription, the pharmacist had time to call the drug
information centre, the manufacturer, and the physician
to confirm the dosage. The doctor confirmed that the dose
was accurate and that the patient could continue taking
all three tablets together, although I q8h would be preferable.
The pharmacist documented the following in the
note section: “confirmed Wellbutrin® dosage (3 qam)
with Dr…., DIRC, GSK, and the patient today. See original
prescription #xxxxxx for more detail.”
This documentation provides concise accurate information
to any pharmacist who will fill or refill a prescription in
the future.
Scenario 2:
When you cannot reach or talk to someone.
It is Friday night at 7:30 when a discharged hospital
patient presents himself to the pharmacy with a prescription
for Atenolol with no strength indicated. Patient
history reveals that the patient was previously on
hydrochlorothiazide 50mg but the patient cannot
remember whether he was to discontinue or continue the
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Pharmacy Connection January • February 2004