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KEY POINTS

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  • MTM currently represents yet another information silo that may have adverse effects on therapeutic outcomes and professional relationships.

  • Barriers to pharmacist documentation are related to culture, workflow, and job descriptions.

  • The Medicare Part D MTM program standardized format describes the content and format required for personal medication lists and medication action plans.

  • The personal medication list, medication action plan, and physician letter do not meet the criteria for complete documentation of the MTM encounter.

  • The care plan is a necessary part of comprehensive documentation of an MTM encounter.

  • Medicare is encouraging the interoperability of MTM software and the electronic health record (EHR) as well as patient access to health information.

  • Risk management rules and risk awareness are important for documentation and using all health information technology, eg, email, EHR, mobile technology, and social media.

  • MTM documentation must be written in a way that is engaging, holds attention, facilitates understanding, and encourages appropriate actions.

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INTRODUCTION

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Documentation is inherent to most professions. Pharmacy has always been on the outside of the medical record looking in and treading lightly. The profession is now at the point where a convergence of law, regulation, performance measures, restructured care, financial realignment, and health information technology make adequate documentation essential for professional growth. The old statement, "If you didn't document it, you didn't do it," could be expanded to say, "If your documentation is not shared with the healthcare team, you are not a team member."

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Another Information Silo

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The typical pharmacy practice involves a professional operating at a physical distance and lacking real insight into the physician's overall therapeutic goals for the patient. The pharmacist has always dispensed advice to patients without documentation or communicating with the physician and other health team members. This separation, with its ensuing lack of information exchange and coordination of care, has not been conducive to professional relationships (see Chapter 6). MTM has now added a new layer of complexity. Some items to consider:

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  1. Why didn't they tell me that? The CMR interview is a unique event in pharmacy practice that will frequently uncover relevant facts unknown to the physician. While patients often confide in pharmacists things they have not shared with their physicians, this information is now documented in a permanent record. One can understand how a physician would be embarrassed on being presented with previously unknown information about a patient with whom he or she had a long-term and seemingly trusting relationship.

  2. I have not thought about this patient since the last visit. The usual interaction between physician and pharmacist is tied to single prescription-related issues and most often occurs just after the patient has come from the physician's office. MTM can take place weeks or months after the last physician visit and may require the prescriber to revisit the patient's chart to determine the appropriate course of action from the interventions ...

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