IMM 11: Documenting Patient Care Flashcards
What is the purpose of written documentation in the healthcare setting?
- improves patient care and safety – patient’s healthcare story, records of HCP actions
- enables efficient communication of assessments and recommendations – continuity of care
- conveys professionalism – allows other health care practitioners to appreciate the importance of your role, demonstrates contribution to patient care
- establishes accountability and responsibility for professional activities
What kinds of pharmacist activities and interventions should be documented?
- description of patient care activities performed – ie. best possible medication history (BPMH), allergy history, admission or discharge medication reconciliation, adverse drug reaction assessment
- actual and potential drug-therapy problems (DTPs) identified
- recommendations for changes in drug therapy, dosage, duration of therapy, and/or route of administration
- interpretation of clinical findings (ie. physical exam findings) or lab results
- recommendations for monitoring of response to drug therapy
- description of follow-up to be conducted by the pharmacist – ie. patient education to be provided, therapeutic drug monitoring
What are pharmacy records?
allows for collection and documentation of patient information primarily for the pharmacist’s reference
ie. local pharmacy computer records, written notations on prescription hard copies, pharmacist work-up and care plan
What are medical charts or health records?
- vehicle used by all health care providers to document their assessment and plan
- allows pharmacists to communicate their recommendations and follow up provided to other health care providers
- ie. consult note, progress or follow-up note, medication history (ie. BPMH), patient medication education (ie. inhaler teaching)
What are the 5 essential components of a clinical note?
- date and time of note
- title of note
- identification of patient involved
- body note
- closing
Clinical Note
Title
- other clinicians should be able to quickly see what your clinical note is about
- if the topic of your note is relevant, they are more likely to read what you have written
- if there is no title, they are more likely to skip your note
- title should indicate who wrote it and the main theme of your note
- ie. “Pharmacist Note RE: Renal Dose Adjustment”
Clinical Note
Identification of Patient
- patient’s name (or initials) and age
- brief statement about presenting problem or chief complaint, relevant medical conditions, occupation
- ie. “Pat is a 45 y.o. male with a long-standing history of asthma”
Clinical Note
Body
- most important part of clinical note
- provide a framework for communication between health care providers about a patient’s condition
- many formats
- SOAP = subjective, objective, assessment, plan
- SBAR = situation, background, assessment, recommendation
- FARM = findings, assessment, recommendations, monitoring
- APSO = assessment, plan, subjective, objective
Clinical Note
Closing
- signed name
- printed name
- designation (ie. “BSc(Pharm)”, “Pharmacist”, “Pharmacy Student”) – students must document they have “discussed” the note with a preceptor and identify the preceptor by name and designation
- contact information (ie. phone number)
What is a SOAP note?
- subjective
- objective
- assessment
- plan
SOAP Note
Subjective
relevant clinical information reported by the patient (or their caregiver)
- chief complaint (including specific symptoms)
- history of present illness
- past or current medical history
- past or current medication history
- allergy history
- social history
- other patient-reported concerns
may be omitted from note if patient unable to relay information (ie. patient is unconscious or intubated) and caregiver is not available or cannot provide information
SOAP Note
Objective
relevant clinical information obtained from sources other than the patient – ie. documented facts found in the patient chart, Medication Administration Record (MAR), PharmaNet, data obtained from measurements
- vital signs
- physical exam findings (using a head-to-toe format)
- laboratory or microbiological data
- diagnostic tests
- current medication therapy
consider documenting source of information – ie. “medications as per PharmaNet”, “nursing notes indicate reduced pain today”, “no PRN acetaminophen administered today for pain as per MAR”
SOAP Note
Assessment
communicates critical thinking and clinical judgment about the DTP(s) based on the subjective and objective data you have already presented
- prioritized list and description of actual or potential DTP(s)
- consideration for desired goals of therapy for this patient
- brief discussion of feasible therapeutic alternatives, including relevant considerations (ie. efficacy, toxicity, patient-specific factors, cost, convenience, pros/cons, etc.)
- rationale for making each recommendation in your “plan” and/or evidence as to why other clinicians should consider your recommendation(s)
should briefly explain your thought process for why you recommended your specific “plan”
SOAP Note
Plan
specific care plan action steps for each identified DTP – “to do” list
- patient-specific recommendations (drug and/or non-drug measures)
- plans to provide patient education (if required)
- monitoring plan for efficacy and toxicity (who, what, when, how often, targets), including recommendations for: repeat laboratory tests, cultures, etc., when the patient should be re-evaluated to determine if they are meeting goals of therapy
consider what steps need to be communicated to other health care practitioners in order for implementation of the plan and effective monitoring and follow-up
plan should consist of a clear and concise list of individual recommendations
- each recommendation should be listed separately
- the list should be numbered and prioritized
- refer to monitoring plan
What is the difference between a Pharmacy Care Plan and a SOAP note?
pharmacy care plans:
- comprehensive type of documentation used to record a pharmacist’s thought process and detailed rationale for identified DTP(s) and proposed recommendations
- usually reserved for use by pharmacists only
SOAP notes:
- short and concise and should summarize and highlight pertinent information from pharmacy care plan
- used to communicate between health care providers
What should you do before writing your clinical note?
- review patient chart
- interview patient
- talk to healthcare team
- refer to patient work-up/pharmacy care plan
