Documentation Guidelines

GUIDELINE

Published: January/February 2004, June 2012

Revised: 2008, 2012

Review Date: 2015

Legislative references:

Additional references:

College Contact: Pharmacy Practice

Purpose: To assist members in meeting the expectations for documentation in pharmacy practice.


Introduction

Documentation is a key element of every health profession’s standard of practice and one of the most basic professional responsibilities. A member demonstrates accountability and responsibility for their actions, and evidence of the application of their medication and medication therapy management expertise, through documentation. Documentation should be organized in such a manner that all professional actions on behalf of a patient are accurately described.

Documentation supports the inter- and intra- professional delivery of patient care, and demonstrates a member’s professional judgment through the interventions and recommendations made on behalf of the patient.1Consistent documentation of patient contacts in the context of medication therapy management leads to improved continuity of care through the availability of up-to-date therapeutic information within a practice location and within the context of the circle of care.2Continuity of care in the treatment of chronic health conditions, such as diabetes, is associated with lower health care costs and higher patient satisfaction.3


Principles

  1. Patient records support the continuity of care and collaboration between and among health professionals;
  2. The documentation of patient care optimizes decision-making, helps to reduce duplication of services and demonstrates the member’s decision-making process;
  3. Good documentation has four important characteristics. It should be: 1) factual; 2) complete; 3) current (timely); and 4) organized.

Definitions

Patient Record

A patient record is the complete account of a patient’s care, including: the patient profile; patient and provider identifying information; data collected; assessment; notes documenting critical thinking and judgment, recommendations, interventions and discussions between members, other health care providers and patients; and prescriptions, records and reports that pertain to the patient’s care.


Guideline

The collection, use, disclosure, retention, and disposal of personal health information is governed by the Personal Health Information Protection Act, 2004. As the legislation regarding the collection and use of personal health information is complex, it is recommended that members review the Guide to the Personal Health Information Protection Act published by the Information and Privacy Commissioner. 4

The owner of the pharmacy is ultimately accountable for the personal health information collected and retained within the pharmacy, including with respect to a remote dispensing location, if any. The Drug and Pharmacies Regulation Act, 1990 establishes specific responsibilities for the Designated Manager of the pharmacy to ensure it meets the requirements established through legislation and regulation and that patient health information is collected and stored appropriately. The College has created a Record Retention, Disclosure and Disposal Guideline to assist members in this area.

The patient record contains all the information required to effectively manage a patient’s drug therapy. Documentation in the record includes any written or electronically generated information about a patient that describes the care or services provided. Supporting data and evidence for clinical decision-making, such as laboratory results, are referenced and, where appropriate, the scanned copies of test results are included.

A member uses professional judgment in determining the extent of documentation and information that should be contained in the patient record. Members should avoid extraneous information and only document what is important. The meaning of any entry into a patient record should be clear to a health care professional reading the record. The level of detail will vary depending on each situation, including when necessary:

  • Date;
  • Identifying information, including that of the member documenting the patient contact;
  • Patient presenting symptoms or concerns (e.g. medication assessment, pharmaceutical opinion, follow-up, etc.);
  • Patient history summary and care plan if developed. (The record should acknowledge whether a care plan was available. If a care plan is part of the patient record it should be acknowledged in the documentation);
  • Documentation of patient’s voluntary and informed or implied consent5 , or that of their substitute decision maker, if any;
  • Information provided to or received from other caregivers;
  • Collaboration undertaken with other caregivers, including outcomes, and/or proposed courses of action;
  • Assessments, interventions, and recommendations where professional judgment was exercised along with the evidence on which the recommendations are based; and
  • A follow-up plan that is sufficiently detailed to monitor the patient’s progress and ensure continuity of care by the pharmacist, and other regulated health professionals or caregivers, if applicable.

Documentation will include pertinent discussions with the patient and prescriber/health care provider, including notes related to patient education, contact information and any communication which occurred or was attempted, information regarding drug use that is deemed important to patient care, or other patient information pertinent to the situation. A sample documentation/notification template that can be utilized or adapted by the member is attached.
All documentation must be legible and non-erasable. Written entries are made in ink, and electronic entries are non-alterable. Notes should not be rewritten, or removed from any files or records; however, changes to recorded information are sometimes required to ensure the accuracy of the record. Where such modifications are made, incorrect information should be clearly labeled as being incorrect when a change is made. In a manual record, errors should be crossed out with a single line and initialed. Notes made by other health professionals or members are not to be altered.


Documentation Styles

Systematic documentation has the advantage of encouraging completeness and consistency of data presentation, as well as improving organization of thought. However, in some circumstances, documentation can prove to be time-consuming, onerous, and confusing (particularly if a pharmacist is unclear as to how to categorize certain types of information). There are a range of documentation styles to choose from that may address this issue, including the use of unstructured notes, semi-structured notes, and the creation of systematic records using established codes. Each style has certain advantages and disadvantages and the appropriate approach should meet the needs of the specific practice site.


1. Unstructured notes are free-form records of patient encounters and care. These notes must be dated and at a minimum identify the member who is making them. The notes should also conform to general conventions of appropriate language use, including the use of accepted abbreviations in a pharmacy setting. The advantages of unstructured notes are that they can be quickly written and can provide an “impressionistic” overview of a situation. Disadvantages of unstructured notes are that they are often incomplete, lack consistency, and have limited value as communication with other health care providers.


2. Examples of approaches to documentation include SOAP, FARM, DRP, DAP and DDAP. These acronyms refer to the general categories of information which are documented:

  • SOAP: information is documented under the categories of Subjective (findings), Objective (findings), Assessment, and Plan;
  • FARM: categories are Findings, Assessment, Recommendations, and Monitoring (and follow-up);
  • DRP: stands for Drug-Related Problem, Rationale, and Plan;
  • DAP: is Data, Assessment, and Plan;
  • DDAP: refers to Drug-Related Problem, Data, Assessment, and Plan.6

Other documentation approaches may be used as long as they are consistent with the therapeutic thought process.

3. Semi-structured approaches use a blend of both systematic and unstructured documentation systems. In these approaches, pharmacists may complement a structured note with additional free-form text to either provide more in depth information or to provide unusual and important details that may not be easily categorized elsewhere. Semi-structured notes can have the same advantages of both unstructured and structured notes, although they often take more time to compose, and may not be as clear and consistent as structured notes. Structured notes may be most appropriate in circumstances where monitoring and follow up are required. Semi-structured or unstructured notes may be more appropriate where general impressions are noted, but no specific action on the part of the pharmacist is required at the time.


Delegation of Controlled Acts

Any delegation of controlled acts will be documented and will follow the principles and practices outlined in the College Policy on Medical Directives and Delegation.


References

  1. Kennie, et. al. Demonstrating value, documenting care: Lessons learned about writing comprehensive patient medication assessments in the IMPACT project PART I: Getting started with documenting medication Assessments. Canadian Pharmacists Journal. Retrieved at: http://www.cpjournal.ca/doi/pdf/10.3821/1913-701X%282008%29141%5B114%3ADVDCLL%5D2.0.CO%3B2
  2. ‘Circle of Care’ is a term commonly used to describe the ability of certain health information custodians to assume an individual’s implied consent to collect, use or disclose personal health information for the purpose of providing health care, in circumstances defined in PHIPA. More information on the term and guidance on access to patient information, is outlined in the document created by Ontario’s Information and Privacy Commissioner: Circle of Care: Sharing Personal Health Information for Health Care Purposes available at www.ipc.on.ca
  3. Lee, et al. (2006). The Evaluation of the Continuity of Care at the Group Health Centre, A Unique Multi-specialty, Multi-disciplinary Health Service Organization. Canadian Health Services Research Foundation. Retrieved on the World Wide Web on May 16, 2011 at: http://www.chsrf.ca/Migrated/PDF/ResearchReports/OGC/lee_final.pdf
  4. Information and Privacy Commissioner. A Guide to the Personal Health Information Protection Act. December 2004.Retrieved at: http://www.ipc.on.ca/images/Resources/hguide-e.pdf
  5. Implied consent is a form of consent which is not expressly granted by a person, but rather inferred from a person's actions and the facts and circumstances of a particular situation (or in some cases, by a person's silence or inaction).
  6. Kennie, et. al. Demonstrating value, documenting care: Lessons learned about writing comprehensive patient medication assessments in the IMPACT project PART I: Getting started with documenting medication Assessments; p.118. Canadian Pharmacists Journal. Retrieved at: http://www.cpjournal.ca/doi/pdf/10.3821/1913-701X%282008%29141%5B114%3ADVDCLL%5D2.0.CO%3B2