Pharmacy Practice

• Documentation in a Patient Health Record is a crucial aspect of pharmacy practice.
• Saskatchewan Health Authority has a work standard for pharmacist documentation in the patients' health record.
• The benefits of documentation include improved transparency & access to relevant, timely patient care information, enhanced communication between health care professionals, demonstration of the level of care provided, measurement of workload & data for research, and compliance with professional, legal & accreditation standards.
• Lack of appropriate documentation by pharmacists could lead to poor pharmacotherapy and medical consequences for patients and/or the healthcare team.
• Documentation is taking responsibility for the care and decisions being made for your patient.
• Shared decision making (SDM) occurs when a healthcare provider (HCP) and a patient collaborate to make a decision that is best for the patient.
• SDM recognizes that patients are experts on what matters most to them.
• The optimal decision takes into account evidence-based information, the provider’s knowledge and experience, and the patient’s goals, values and preferences.
• Guidelines are recommending SDM more frequently.
• Documentation should include date and time of note, title of note, and the patient’s subjective experience with medication.
• Suggestion should not include extra rationale or monitoring that does not need to be implemented.
• The “S” in IRS stands for suggestion, which includes decisions or recommendations for changing drug therapy and monitoring drug therapy and follow-up.
• Drug therapy problems identified should be listed in the rationale section.
• The “I” in IRS stands for issue, which outlines the reason for the note.
• Common errors when using IRS include including too much detail and not addressing purpose for the note.
• The “R” in IRS stands for rationale, which provides overall data/information to support the care plan.
• Conclusions, action plans, or recommendations should be listed in the rationale section.
• The rationale should be the background and reasons that support your suggestion.
• Communication with other healthcare professionals should be listed in the rationale section.
• UK websites: https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/shared-decision-making
• Briefly describe your rationale.
• Ottawa Hospital decision aids: https://decisionaid.ohri.ca/AZinvent.php
• Mayo Clinic: https://carethatfits.org/shared-decision-making/
• AHRQ SHARE Tools: https://www.ahrq.gov/health-literacy/curriculum-tools/shareddecisionmaking/tools/index.html
• The pharmacist suggests the best option for treating pneumonia in the patient who cannot take oral medications would be ceftriaxone 1g IV daily as there is good lung penetration, covers most organisms responsible for community acquired pneumonia and is conveniently dosed.
• The pharmacist informs the physician/resident about the patient’s anaphylactic penicillin allergy.
• The pharmacist finds out that Piperacillin/Tazobactam is being used for pneumonia in a patient that cannot take anything PO due to current level of consciousness.
• In Verbal Communication Case #1, the pharmacist pages the physician/resident who wrote the order to discuss the issue.
• Verbal Communication with Prescribers involves confirming the prescriber is responsible for communicating any issues requiring patient communication, identifying the issue, usually a drug therapy problem, clearly stating your recommendation, briefly describing your rationale, having a plan “B” and “C” in mind, confirming the agreed upon solution, documenting and communicating to others involved as required.
• In Verbal Communication Case #1, a pharmacist working on Patient X’s orders receives an order for Piperacillin/Tazobactam in a patient who has an anaphylactic penicillin allergy.
• Identify the issue, usually a drug therapy problem.
• Confirm agreed upon solution.
• The best alternative for this patient is ceftriaxone (or moxifloxacin IV as option B).
• The pharmacist documents the change in medication as per discussion and sends to unit.
• The physician/resident who wrote the order agrees with the change in medication to ceftriaxone 1g IV daily.
• Always have a plan “B” and “C” in mind.
• Clearly state your recommendation.
• The prescriber is responsible for communicating any issues requiring patient communication.
• The physician/resident who wrote the order can be confirmed by the pharmacist.
• Document and communicate to others involved as required.