Flip the Script: Changing Documentation Standards and Establishing Best Practices for Pharmacists in a Primary Care Setting.

Abstract

Documentation of clinical encounters continues to be a challenge to implement in practice and there is a lack of literature on documentation best practices in pharmacy. In order to inform documentation practices at an academic pharmacy clinic, a quality assurance (QA) initiative was implemented at the UBC Pharmacists Clinic (the Clinic). The goal of this QA initiative was to determine what facilitators and barriers to documentation existed for Clinic pharmacists and improve the efficiency of consultation note writing. Phase 1 conducted an online survey to assess each pharmacist's documentation practice at baseline. Phase 2 implemented new interventions that could advance these skills. There were five main interventions introduced: 1) revised consultation note templates, 2) a documentation "checklist", 3) a documentation "decision tree", 4) a clinical documentation guide and 5) a documentation peer-feedback workshop. During Phase 3, pharmacists re-answered the same survey questions 10 months later. This allowed for a direct comparison of documentation practices and skills before and after the interventions. After the interventions, pharmacists reduced the time to complete their notes by nearly 14 min. The revised note structure resulted in an increased uptake of template use from 37% to 100%. Furthermore, prior to the interventions, the majority of pharmacists ranked writing consultation notes as the most burdensome aspect of their daily workflow. Afterwards, the perceived level of burden reduced significantly. These findings can be used to inform how students are taught documentation and improve the quality of documentation by pharmacists in team-based or primary care settings.