Chapter 2. Documentation

After reading this chapter, the pharmacy student, community practice resident, or pharmacist should be able to:

1. Establish documentation practices that can be easily integrated into a community pharmacy's workflow.

2. Utilize the assistance of ancillary staff, student pharmacists, residents, and staff pharmacists in documenting clinical services within the community pharmacy setting.

3. Develop a method for documenting pharmacist interventions and patient outcomes within the community pharmacy setting that abide by state and federal law.

4. Report these outcomes to other members of the pharmacy team, other health-care providers, and third-party payers in support of the value of clinical pharmacist services within the community pharmacy setting.

5. Apply these outcomes to improve clinical practice within the community pharmacy setting.

“If it isn't documented, it didn't happen,” is a statement that resonates with many pharmacists and other health-care professionals. Whether it was during a pharmacy law class or during clinical rotations, the first time a pharmacist hears this quote marks the beginning of a dedication to documentation. From product verification to narcotic inventories, documentation is required for most activities performed by a pharmacist. For years, the act of documentation by pharmacists served as a means to assign ownership. Documenting that a bottle of Oxycontin® (oxycodone ER) was double counted or placing initials on a work log assigned liability and protects both the pharmacist and the patient in the event of unexpected adverse effects or achievement of optimal therapeutic response.

The livelihood of a pharmacist continues to rely largely on documentation practices as the profession expands clinical services in outpatient practice settings, namely community pharmacies. As pharmacists' authorities expand beyond providing vaccinations and therapeutic drug-level monitoring, documentation practices have become more intricate, most cases requiring more that just initials to not only establish ownership but payment for services as well.

Proper documentation is required by state and federal law for pharmacists to be reimbursed for the provision of clinical services, such as immunizations and medication therapy management (MTM) services. Documentation is mandatory to operate any patient care practice.

Cipolle, Strand, and Morley have defined documentation in the following manner: “Documentation refers to all patient-specific information, the clinical decisions, and the patient outcomes that are recorded for use in practice. This includes everything written down in long-hand, or entered into a computer program that becomes data and is used to facilitate the care of patients.”1 Pharmacy as a profession has come a great distance in terms of documentation of patient care services, but the profession lacks a uniform method of documentation and billing of clinical services.2 Key stakeholders within the health-care system have recognized that as a limiting factor, and while this chapter will not solve the problem of a universal electronic health record (EHR), it will highlight the importance of documentation and describe key components that will be required for the documentation of patient care services.

Documentation is necessary for a spectrum ...