Documentation of Patient Care Services in a Community Pharmacy
Objective: To assess the types of patient care documentation systems currently being used by community pharmacists and determine the preferred characteristics of an ideal patient care documentation system.
Design: Mailed survey.
Setting: United States.
Participants: One pharmacist from each of 125 targeted community pharmacies.
Intervention: Survey mailed in February 2003, followed by a second mailing to nonrespondents in March 2003.
Main Outcome Measures: Responses to survey items about (1) patient care services provided at the pharmacy, (2) characteristics of the current documentation system, and (3) characteristics of an ideal documentation system.
Results: A total of 48 usable responses were received from 106 pharmacies to which surveys were delivered (45.3%). Independent pharmacies accounted for 50% of survey respondents. More than 80% of respondents were providing patient screening or management services associated with a chronic disease such as diabetes, hypertension, or dyslipidemia. Approximately 54% of the pharmacists were using a paper documentation system. However, challenges identified with a paper system included documentation time, retrieval of patient data, tracking patient outcomes, and storage. Respondents indicated that an ideal documentation system would be comprehensive, easy and efficient to use, and affordable.
Conclusion: Pharmacists recognize the importance of documenting patient care services. While the majority of respondents are using paper charts to document patient care services, computerized systems appear to offer advantages over paper charts. This information offers community pharmacists a summary of previous experiences and a starting point when trying to identify or modify a documentation system that would better meet the pharmacies' needs.
Community pharmacists are expanding patient care services to enhance their role as pharmaceutical care providers. Examples of expanded patient care services include point-of-care testing for cholesterol, glucose, osteoporosis, and blood pressure screenings, and providing patient consultations for glucose meter trainings, medication reviews, and other drug therapy management programs. Through these services, pharmacists are able to enhance patient education and use objective patient data to collaborate with the patient and the patient's physician to manage drug therapy and improve outcomes. Pharmacists' involvement in expanded patient care services has led to improvement in patients' glycosylated hemoglobin (A1C) levels, lipid levels, blood pressure control, asthma management, and health-related quality of life.
A specific example of pharmacists providing enhanced patient care is in Asheville, N.C., where pharmacists provide pharmaceutical care for patients with diabetes and asthma. Patients enrolled in the original Asheville Project met with pharmacists to receive diabetes education to improve medication adherence and to establish and monitor treatment goals. Pharmacist providers for the Asheville Project were able to document improved clinical outcomes for patients with diabetes and improved economic outcomes for the self-insured employers, who were the primary insurers for the patients enrolled in the project. The patients who received ongoing pharmaceutical care services for diabetes achieved and maintained improvement in hemoglobin A1C levels. In addition, the employers recognized a decrease in total mean direct medical costs per patient, decreased employee sick days, and increased productivity. Pharmacists documented their services and were compensated by the employers for the services provided. Similar results were reported recently for employees and dependents with asthma.
Documentation is a critical component of enhanced patient care services. A pharmacist must be able to provide a clear record of the care provided to the patient at each encounter. A tool has been developed to provide guidelines that help pharmacists identify essential information that should be included in the documentation of pharmaceutical care. Accurate documentation allows the pharmacist, other health care providers, and third-party payers to assess the quality of the care provided and track the effect of pharmaceutical care on clinical, humanistic, and economic outcomes. Documentation of quality patient care and improved outcomes provides justification for payment of pharmaceutical care services.
Documentation of pharmacy services can be time consuming and to facilitate the delivery of pharmaceutical care, pharmacists may consider the use of technology to document patient care services and track patient outcomes. Each pharmacy setting is unique, and the ultimate question surrounding documentation is how to decide which system meets the needs of the individual practice site. Limited information is available in the literature evaluating computerized systems for documentation of pharmacy services. The goal of this project was to collect information from community pharmacists about their current documentation systems and develop a resource that provides assistance in evaluating currently available computerized documentation systems.
Abstract and Introduction
Abstract
Objective: To assess the types of patient care documentation systems currently being used by community pharmacists and determine the preferred characteristics of an ideal patient care documentation system.
Design: Mailed survey.
Setting: United States.
Participants: One pharmacist from each of 125 targeted community pharmacies.
Intervention: Survey mailed in February 2003, followed by a second mailing to nonrespondents in March 2003.
Main Outcome Measures: Responses to survey items about (1) patient care services provided at the pharmacy, (2) characteristics of the current documentation system, and (3) characteristics of an ideal documentation system.
Results: A total of 48 usable responses were received from 106 pharmacies to which surveys were delivered (45.3%). Independent pharmacies accounted for 50% of survey respondents. More than 80% of respondents were providing patient screening or management services associated with a chronic disease such as diabetes, hypertension, or dyslipidemia. Approximately 54% of the pharmacists were using a paper documentation system. However, challenges identified with a paper system included documentation time, retrieval of patient data, tracking patient outcomes, and storage. Respondents indicated that an ideal documentation system would be comprehensive, easy and efficient to use, and affordable.
Conclusion: Pharmacists recognize the importance of documenting patient care services. While the majority of respondents are using paper charts to document patient care services, computerized systems appear to offer advantages over paper charts. This information offers community pharmacists a summary of previous experiences and a starting point when trying to identify or modify a documentation system that would better meet the pharmacies' needs.
Introduction
Community pharmacists are expanding patient care services to enhance their role as pharmaceutical care providers. Examples of expanded patient care services include point-of-care testing for cholesterol, glucose, osteoporosis, and blood pressure screenings, and providing patient consultations for glucose meter trainings, medication reviews, and other drug therapy management programs. Through these services, pharmacists are able to enhance patient education and use objective patient data to collaborate with the patient and the patient's physician to manage drug therapy and improve outcomes. Pharmacists' involvement in expanded patient care services has led to improvement in patients' glycosylated hemoglobin (A1C) levels, lipid levels, blood pressure control, asthma management, and health-related quality of life.
A specific example of pharmacists providing enhanced patient care is in Asheville, N.C., where pharmacists provide pharmaceutical care for patients with diabetes and asthma. Patients enrolled in the original Asheville Project met with pharmacists to receive diabetes education to improve medication adherence and to establish and monitor treatment goals. Pharmacist providers for the Asheville Project were able to document improved clinical outcomes for patients with diabetes and improved economic outcomes for the self-insured employers, who were the primary insurers for the patients enrolled in the project. The patients who received ongoing pharmaceutical care services for diabetes achieved and maintained improvement in hemoglobin A1C levels. In addition, the employers recognized a decrease in total mean direct medical costs per patient, decreased employee sick days, and increased productivity. Pharmacists documented their services and were compensated by the employers for the services provided. Similar results were reported recently for employees and dependents with asthma.
Documentation is a critical component of enhanced patient care services. A pharmacist must be able to provide a clear record of the care provided to the patient at each encounter. A tool has been developed to provide guidelines that help pharmacists identify essential information that should be included in the documentation of pharmaceutical care. Accurate documentation allows the pharmacist, other health care providers, and third-party payers to assess the quality of the care provided and track the effect of pharmaceutical care on clinical, humanistic, and economic outcomes. Documentation of quality patient care and improved outcomes provides justification for payment of pharmaceutical care services.
Documentation of pharmacy services can be time consuming and to facilitate the delivery of pharmaceutical care, pharmacists may consider the use of technology to document patient care services and track patient outcomes. Each pharmacy setting is unique, and the ultimate question surrounding documentation is how to decide which system meets the needs of the individual practice site. Limited information is available in the literature evaluating computerized systems for documentation of pharmacy services. The goal of this project was to collect information from community pharmacists about their current documentation systems and develop a resource that provides assistance in evaluating currently available computerized documentation systems.
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