Jean-Philippe Adam1, Chloé Trudeau2, Charlotte Pelchat-White3, Marie-Lou Deschamps4, Philippe Labrosse5, Marie-Claude Langevin6, Benoît Crevier7. 1. , BPharm, MSc, BCPS, BCOP, is with the Pharmacy Department, Centre hospitalier de l'Université de Montréal (CHUM), and the Centre de recherche du CHUM, Montréal, Quebec. 2. , PharmD, MSc, was, at time of this study, a pharmacy student in the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec. She is now with the Pharmacy Department, Centre hospitalier de l'Université de Montréal. 3. , PharmD, was, at time of this study, a pharmacy student in the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec. She is now with the Uniprix Pharmacy Jean-Pierre Bois et François Dupuis, Mascouche, Quebec. 4. , PharmD, was, at time of this study, a pharmacy student in the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec. She is now with the Pharmacy Department, McGill University Health Centre, Montréal, Quebec. 5. , PharmD, was, at time of this study, a pharmacy student in the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec. He is now with the Pharmacy Department, CISSS de la Montérégie-Centre, Longueil, Quebec. 6. , BPharm, MSc, is with the Pharmacy Department, Centre hospitalier de l'Université de Montréal, Montréal, Quebec. 7. , PharmD, MSc, BCCP, was, at time of this study, with the Pharmacy Department, Centre hospitalier de l'Université de Montréal, Montréal, Quebec. He is now with the Pharmacy Department, CISSS de la Montérégie-Centre, Longueil, Quebec.
Abstract
BACKGROUND: In many studies on documentation, the data are self-reported, which makes it difficult to know the actual level of documentation by pharmacists in patients' medical records. The literature assessing documentation by clinical pharmacists in health care centres is limited. OBJECTIVE: To assess the level of documentation in patients' medical records by clinical pharmacists at one large urban hospital. METHODS: This retrospective observational study included all patients who were followed by a clinical pharmacist during their stay in the Centre hospitalier de l'Université de Montreal between July 1 and October 31, 2016. The primary outcome, the level of documentation in patients' medical records, was categorized as minimal, sufficient, or extensive. The quality of notes and the impact of pharmacy students and residents on documentation were evaluated as secondary outcomes. RESULTS: A total of 779 patient charts from 4 inpatient units were included in the analysis. Of these, 563 (72.3%) were considered to have minimal documentation (at least 1 intervention described in writing), 432 (55.5%) had sufficient documentation (at least 1 note written during the patient's hospitalization), and 81 (10.4%) had extensive documentation (appropriate number of notes in relation to duration of hospitalization). Medication reconciliation performed by pharmacists at the time of admission was documented in 696 (89.3%) of patients' records. The presence of students or residents on a clinical unit was associated with a significant increase in the percentage of charts with at least 1 follow-up note (23.6% [120/508] with students/residents versus 12.5% [34/271] without students/residents; p < 0.001) and the mean number of followup notes (0.59 versus 0.23, respectively; p < 0.001) but had no effect on other variables. Of a total of 777 notes written by a pharmacist, the overall conformity with pre-established criteria was 56.8% (441/777), and conformity was 43.4% (139/320), 75.1% (272/362), and 31.6% (30/95) for admission, follow-up, and discharge notes, respectively. CONCLUSIONS: Documentation by clinical pharmacists in patients' medical records could be improved to achieve the stated goal of the American Society of Health-System Pharmacists and the Canadian Society of Hospital Pharmacists, that all significant clinical recommendations or interventions should be documented.
BACKGROUND: In many studies on documentation, the data are self-reported, which makes it difficult to know the actual level of documentation by pharmacists in patients' medical records. The literature assessing documentation by clinical pharmacists in health care centres is limited. OBJECTIVE: To assess the level of documentation in patients' medical records by clinical pharmacists at one large urban hospital. METHODS: This retrospective observational study included all patients who were followed by a clinical pharmacist during their stay in the Centre hospitalier de l'Université de Montreal between July 1 and October 31, 2016. The primary outcome, the level of documentation in patients' medical records, was categorized as minimal, sufficient, or extensive. The quality of notes and the impact of pharmacy students and residents on documentation were evaluated as secondary outcomes. RESULTS: A total of 779 patient charts from 4 inpatient units were included in the analysis. Of these, 563 (72.3%) were considered to have minimal documentation (at least 1 intervention described in writing), 432 (55.5%) had sufficient documentation (at least 1 note written during the patient's hospitalization), and 81 (10.4%) had extensive documentation (appropriate number of notes in relation to duration of hospitalization). Medication reconciliation performed by pharmacists at the time of admission was documented in 696 (89.3%) of patients' records. The presence of students or residents on a clinical unit was associated with a significant increase in the percentage of charts with at least 1 follow-up note (23.6% [120/508] with students/residents versus 12.5% [34/271] without students/residents; p < 0.001) and the mean number of followup notes (0.59 versus 0.23, respectively; p < 0.001) but had no effect on other variables. Of a total of 777 notes written by a pharmacist, the overall conformity with pre-established criteria was 56.8% (441/777), and conformity was 43.4% (139/320), 75.1% (272/362), and 31.6% (30/95) for admission, follow-up, and discharge notes, respectively. CONCLUSIONS: Documentation by clinical pharmacists in patients' medical records could be improved to achieve the stated goal of the American Society of Health-System Pharmacists and the Canadian Society of Hospital Pharmacists, that all significant clinical recommendations or interventions should be documented.
Authors: John M Burke; William A Miller; Anne P Spencer; Christopher W Crank; Laura Adkins; Karen E Bertch; Dominic P Ragucci; William E Smith; Amy W Valley Journal: Pharmacotherapy Date: 2008-06 Impact factor: 4.705
Authors: Seena Zierler-Brown; Timothy R Brown; David Chen; Robert Wayne Blackburn Journal: Am J Health Syst Pharm Date: 2007-09-01 Impact factor: 2.637