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Lec (5) Documentation PDF

There are three types of pharmacist interventions: formal consultations requested by physicians, informal consultations requested by healthcare providers, and unsolicited interventions. Pharmacist interventions should be documented in the patient's medical record to provide transparency between healthcare professionals. Documentation should include the date, intervention type, drug, prescriber information, time spent, and whether the intervention was accepted. High priority interventions to report include preventing allergies, avoiding duplicate therapy, adjusting doses, preventing contraindications, avoiding drug interactions, and switching to less expensive but equally effective drugs.

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Ibraheem Ali
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29 views11 pages

Lec (5) Documentation PDF

There are three types of pharmacist interventions: formal consultations requested by physicians, informal consultations requested by healthcare providers, and unsolicited interventions. Pharmacist interventions should be documented in the patient's medical record to provide transparency between healthcare professionals. Documentation should include the date, intervention type, drug, prescriber information, time spent, and whether the intervention was accepted. High priority interventions to report include preventing allergies, avoiding duplicate therapy, adjusting doses, preventing contraindications, avoiding drug interactions, and switching to less expensive but equally effective drugs.

Uploaded by

Ibraheem Ali
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Dr. Shaimaa Khamis, Pharm-D, PhD. 14



 There are generally three types of pharmacist
interventions:
 Formal consultations solicited by physicians
 Informal consultations solicited by physicians and
health care providers
 Unsolicited interventions.
 PI should be documented and reported.

Dr. Shaimaa Khamis, Pharm-D, PhD. 15


Where?

 PI should be documented in the PMR through the
Electronic Medical Record or by Paper in the
Medical Chart.
 That will provide transparency between all health
care professionals (physicians, nurses, pharmacists,
dietitians, respiratory therapists, and social workers).

Dr. Shaimaa Khamis, Pharm-D, PhD. 16


How?

 Pharmacists should be trained and educated to
document in the PMR.
 Documentation methods may include the use of
standard format documentation methods such as:
 SOAP (subjective, objective, assessment, plan)
 TITRS (title, introduction, text, recommendation,
signature)
 FARM (findings, assessment, resolution, and
monitoring)

Dr. Shaimaa Khamis, Pharm-D, PhD. 17


Unsolicited PI

 Unsolicited pharmacist interventions should be
documented, allowing the primary provider to
decline the recommendation without incurring
liability.
 Phrases that can be used include:
 “May consider”
 “Suggest”
 “May recommend”
 Alternatively, the wording for solicited consultations
may be more direct.

Dr. Shaimaa Khamis, Pharm-D, PhD. 18


Oral Communication

 When feasible, written notes by pharmacists should be
documented in the PMR after an oral communication
with the clinician.
 Pharmacists should follow up on their patient
interventions daily and provide follow-up notes that
include patient progress or new interventions, when
needed.

Dr. Shaimaa Khamis, Pharm-D, PhD. 19


Documentation of elements interventions for
reporting to other hospital committees such as the
P&T committee

1. Date, time
2. Type of intervention
3. Drug used
4. Prescriber name, service, and type (attending or
resident)
5. Duration of time spent completing the intervention
6. Whether the intervention was accepted, denied, or
clarification achieved

Dr. Shaimaa Khamis, Pharm-D, PhD. 20


Types of PI that can be reported:

1. Discontinue drug
 12. Non-formulary switch to
2. Switch drug formulary
3. Switch drug for less expensive 13. Non-formulary approval
but equally safe and effective drug 14. Drug unavailable
4. Drug dosing 15. IV drug incompatibility
5. Drug dosage form 16. Drug-drug interaction
6. Drug route 17. Drug-food interaction
7. Pharmacokinetic consultation 18. Drug-laboratory test
8. Pharmacotherapy consultation interaction
9. IV-to-PO switch therapy 19. Pharmacogenomics
10. Contraindication interaction
11. Duplicate therapy 20. Therapeutic interchange

Dr. Shaimaa Khamis, Pharm-D, PhD. 21


Types of PI that can be reported:

21. Allergy prevention


 31. Monitoring for toxicity
22. Medication reconciliation 32. Ordering laboratory tests for
23. Discharge counseling monitoring drug efficacy and
24. Written patient education toxicity
provided 33. Clarification of medication
25. Patient adherence to order
medications 34. Untreated indication
26. Adverse drug reaction 35. Failure to receive medication
27. Overdosage 36. Immunization
28. Subtherapeutic dose recommendation
29. Medication error 37. Immunization administered
30. Monitoring for efficacy 38. Health risk assessment
39. Rapid response interventions
Dr. Shaimaa Khamis, Pharm-D, PhD. 22
Examples of high-priority PT interventions
that should be reported

1. Allergy prevented
2. Duplicate therapy avoided
3. Drug dosing adjustments
4. Contraindication prevented
5. Drug interactions avoided
6. Ordering laboratory tests for monitoring of drug safety
and efficacy
7. Medication reconciliation intervention
8. Switching drug for less expensive but equally safe and
effective drug

Dr. Shaimaa Khamis, Pharm-D, PhD. 23


Dr. Shaimaa Khamis, Pharm-D, PhD. 24

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