The Pharmaceutical Journal
Vol 278 No 7434 p47
13 January 2007

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• Pharmacy practice
• Health economics
• Dispensing errors
• Controlled drugs
• Ethics
• Adverse events
• Regulation
• Fitness to practise
• The Society (2)
• Retention fees (5)
• Pharmacy politicians
• The Journal (2)

Letters to the Editor

Pharmacy practice

Keeping records is essential for patient safety

From Professor D. H. Cousins, MRPharmS, and others

We write in reply to Wing Tang’s letter (PJ, 11 November 2006, p571) regarding paperwork and community pharmacy. We believe that Mr Tang has missed the point in terms of the reasons why it is good practice for professionals to keep records of their clinical activity. Rather than view record keeping as unnecessary bureaucracy made at the behest of primary care trusts, the keeping of clinical notes should be regarded as essential safe practice designed to protect patients.

Pharmacy is one of the few, if not the only, health profession that does not routinely make records of clinical practice. The information kept in patient medication records is limited and clearly does not usually cover the issues raised by Mr Tang. If we are to move from providing a primarily technical and supply role to a more clinical role, we need to record all important clinical information generated during our interactions with a patient to assist the provision of clinical care to that patient both by ourselves and by other colleagues in the future.

Clinical record systems should be developed for pharmacy services that ensure safe and effective care for patients. We should all be willing to keep good clinical records because we want to do a good job for our patients. As a by-product of record keeping for patients (and with little additional effort) we should be able to generate information for others concerned with monitoring safety, quality and effectiveness. However, the generation of this information should be seen as a secondary reason for record keeping, not as the primary reason.

Perhaps it is the use of the term “log” that implies that recording information on these forms is not primarily intended to benefit patients and the various logging systems are insufficiently well linked or patient-centred.

What is clear is that the development of easy-to-use clinical record systems that pharmacists and pharmacy technicians will wish to use to help patients is critical for the provision of clinical pharmacy services in all sectors in the future.

David Cousins
Bruce Warner
Linda Matthew
Catherine Dewsbury
Safe Medication Practice Team
National Patient Safety Agency

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