The Pharmaceutical Journal Vol 267 No 7159 p150
4 August 2001

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Keeping proper documentation is the key to professional development

By Isaac Otomewo

How many of us have had a conversation like this? “What do you do then?” “I’m a pharmacist.” “Oh, so you count tablets all day then.” “No. With my expert knowledge of drugs I get involved in therapeutic decision making and advise patients how to best use their drugs.” “Yes. But can you prove it?”

With the increasing emphasis on evidence-based medicine, it is essential for pharmacists to demonstrate their ability to optimise and improve quality of care and be cost-effective. The new National Health Service talks about organisations (eg, pharmacy) being accountable for continuously improving the quality of their service and safeguarding high standards of care by creating an environment in which clinical excellence can flourish. In order to deliver the improved standards of patient care that clinical governance requires, pharmacy needs to change. We need to change the way we work. Evaluation of clinical pharmacy services and its effect on patient outcome is going to become increasingly important.

If our aim is to deliver the highest standards of pharmaceutical care then we must document that care, or else we might as well count tablets all day. If we as pharmacists want to be taken seriously as a profession then we need to document what we do, when we do it. If a patient goes to see any other health care professional, relevant aspects of the consultation are documented whether the person consulted is a doctor, a nurse, a chiropractor or an osteopath. We need to document our clinical activities; these clinical activities need to be evaluated, validated and continuously improved.

When dealing with the sale or supply of medicines pharmacists are excellent at documenting what they do. One only has to look at the Medicines, Ethics and Practice guide and you can see how the Medicines Act 1968 and the Poisons Act 1972 stipulate what pharmacists may and may not supply, how they can supply it and the records they need to keep.

But when it comes to individual pharmacists documenting clinical interventions pharmacists in both primary and secondary care seem to do little. Why is this?

I accept that pharmacies are busy places and that documentation of clinical activities takes time. Many may see it as an unnecessary burden. But if pharmacists do not provide evidence that they do more than count tablets all day the profession of pharmacy will become like a stagnant pool. Pharmacy needs to develop a standardised systematic format that allows pharmacists in any practice setting to document the evaluation of a patient’s pharmacotherapy.

I appreciate that for pharmacist to document every clinical decision or input they have made for a patient would be a massive task. Let us imagine, however, the mass of information that we would have at our disposal if we all did this for a month. Documentation of interventions can serve two purposes: it documents the provision of pharmaceutical care to individual patients, and provides information to managers that pharmaceutical care is a cost-effective use of health care resources, thus giving them the power to expand the service provided.

Let us take that second point: documentation would provide the proof that pharmaceutical care delivered by pharmacists is a cost-effective use of health care resources. The Government would have to listen. We could then use this information in a hospital setting to provide information to managers to justify and expand the level of service provided.

The situation in hospital pharmacy is such that unless a pharmacist is taking a clinical diploma, then documentation of interventions is variable. When pharmacists do record interventions, the records are often kept in pharmacy. Rarely will a pharmacist document interventions in a patient’s notes. Why is this? Input from a pharmacist in therapeutic decision-making is important to the multidisciplinary team. A physiotherapist may write in the notes that he patient walked up stairs today. An occupational therapist may write that the patient was able to make a cup of tea. Both of these are valuable and important pieces of information that need to be documented. A pharmacist on the other hand will not write, for example, that the patient is on morphine sulphate tablets but no laxative, and if the patient is allowed to get constipation then it will be difficult to treat.

From a medicolegal point of view, one can see how there could be repercussions if the advice given by a pharmacist was correct and ignored or, conversely, incorrect but acted upon. That aside, there should still be consistent systems in place that allow patients to get the same quality of pharmaceutical care wherever they are.

As far as community pharmacy is concerned, it feels like a winter of discontent and that we have been out in the cold too long. All community pharmacists need to do is to become actively involved in primary care organisations.

Pharmacies tend to be welcoming places where patients feel comfortable to talk about any problems they may have with their medicines and their general state of health. A pharmacist may see an asthma, arthritis or angina patient at least every two to three months, whereas a doctor may only see them once every six months to a year. Who is in the best position to review their medication?

Often patients tell pharmacists things that they have not told their GPs and pharmacists need to make sure that such information gets back to the GPs.

A team approach is needed where the pharmacist will be required to support patients in their effort to reach the therapeutic goals of which the doctor, patient and pharmacist would all be aware. Thus pharmacist and doctor could work together in a synergistic fashion increasing the likelihood of a positive patient outcome. Via the NHSnet, pharmacists could view certain section of patient notes and add pharmaceutical care plans.

With the advent of primary care trusts we could see remuneration of pharmacy change totally, with primary care trusts paying pharmacists for clinical services. Pharmacists would have to document what clinical services they were providing in order to get paid.

Pharmacy needs to be more proactive; it needs to set an agenda. We have been waiting since 1998 for the Government to come up with a strategy for community pharmacy. Have we all really taken clinical governance on board? I think not. If we have not made the first step, how can we expect the Government to take us seriously?

We need to act now before it is too late. The Government is already talking about extending nurse prescribing. The Crown review recommended the implementation of independent and dependent prescribers. Pharmacy needs to get involved in this. Is this something that is only going to be for specialist hospital pharmacist? Why should it be? What about the specialist community pharmacist?

The future is bright there are many opportunities. Pharmacists just need to be ready to grasp them.

Mr Otomewo is a pharmacist working in the West Midlands