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  • Knowing how to document is an essential part of being a member of the medical team. The old adage, “If you didn’t document it, it didn’t happen,” still holds true.

  • Pharmacists can deliver medication therapy management (MTM) services anywhere, including the pharmacy, clinic, hospital, or even inside the patient’s home. This physical separation from prescribers creates unique barriers that need consideration prior to documentation.

  • The Patient Protection and Affordable Care Act (PPACA) mandates that pharmacists should document MTM encounters; however, precise instructions on how to document have yet to be determined.

  • The pharmacy community at large is still searching for ways to implement strategies that will allow a bidirectional flow of clinical and medication-related information.

  • Barriers to documentation include, but are not limited to: where does MTM fit into work flow in retail pharmacies, how do pharmacists feel about documenting patient encounters, and how can a patient’s complete medical record be used to document an MTM encounter?

  • The documentation requirements that Medicare defines are: each patient who completes an MTM appointment must receive a personal medication list (PML) and medication action plan (MAP).

  • CMS has not created a standardized way of communicating recommendations to prescribers. Eventually, the PML, MAP, and prescriber communication have to be integrated into a multidisciplinary care plan to coordinate patient care.

  • In order to be recognized as a Medicare provider and bill for services, providers need to know how to document services appropriately, and pharmacists are no exception. In order to be MTM providers and bill Medicare, a documentation process needs to be established.

  • Electronic health records (EHRs) improve continuity of care. MTM software should abide by similar standardization requirements.

  • As patients gain more access to their health records, personal health records (PHR) need to be Health Insurance Portability and Accountability Act (HIPAA) compliant and user-friendly.

  • Documentation evaluations traditionally focus on presence or absence of documentation and clinical accuracy. The challenge is establishing methods to measure the documentation efforts of individual providers.

  • Pharmacists can minimize documentation errors by being: correct, complete, concise, consistent, and cautious.


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.”

Becoming a deemed Medicare provider is going to require the pharmacist be able to follow Medicare rules on evaluation and management (E&M) to be reimbursed and avoid being fined for inadequate documentation. In addition, quality improvement requires that everyone’s contribution, or lack of, be part of the record for evaluation. The pharmacist’s ...

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