Documentation

Documentation is one of the four domains that is evaluated during a pharmacist practice assessment.

Complete, accessible documentation is critical for the provision of continuity of care for your patients. Information that should be documented in the patient record includes data collected, the patient assessment, decisions made and their rationale, follow up, and dialogue with the patient and other members of their healthcare team.

All records and documents generated by members, and through the operation of the pharmacy, must be kept according to the Standards of Practice, Code of Ethics, and as required by legislation and regulation.