Chapter 9. Documentation in Practice

1. All patient care that is provided as medication management services must be documented to meet ethical, professional, and legal guidelines and standards.

2. The patient's Electronic Therapeutic Record is the basis for record-keeping for medication management services.

3. The Patient's Personalized Care Plan contains the information that is most useful to the patient and having this information allows the patient to actively participate in his care.

4. The Electronic Therapeutic Record provides physicians and other practitioners with unique, comprehensive, and useful information about all of the patient's medications, drug therapy problems, and recommendations to optimize the patient's medications.

5. The documentation of medication management services generates the data you will need to manage, expand, improve, and justify your service.

6. Governmental guidelines will require documentation systems used by pharmaceutical care practitioners to (a) meet meaningful use criteria, (b) communicate with other patient care systems, and (c) generate research data to improve patient care and population health in the future.

7. If you didn't document it, you didn't do it!

It is the responsibility of all who provide direct patient care services to document three major categories of information: (a) the data used to make the decisions that fall within your scope of responsibility, (b) the decisions made for and with the patient, and (c) the actual outcomes that result from those decisions. Practitioners who provide medication management services are expected to meet this same standard. Documentation of patient care services is more than making a note or generating medication lists, it is recording the complete care process.

Records used to document medication management services are called the “Electronic Therapeutic Record.” Although it is possible to learn the practice of pharmaceutical care from a paper form of documentation, today it is nearly impossible and mostly impractical to manage a patient care practice with a paper system. This is why we refer to the “electronic” portion of this term. We call it a “therapeutic” record to differentiate it from the dispensing system output. Although information stored in an electronic dispensing system can be useful, it is quite limited in its value when managing a patient's medications. This record only includes prescription products; it only includes information about how the prescription was written, but not how it is actually being taken; and it does not accommodate recommendations made to change medications. The final word in the term is “record” because you will need a longitudinal record of the patient's care you provide. So, when medication management services are provided, we will refer to the documentation that follows as the patient's electronic therapeutic record.

We will discuss each of the documentation elements needed to provide quality care in detail, but first we ...