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

Innovations in pharmacy Pub Date : 2024-05-31 eCollection Date: 2024-01-01 DOI:10.24926/iip.v15i2.6147
Nicole Domanski, Carmen Leung
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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.

翻转剧本:改变记录标准,为基层医疗机构的药剂师确立最佳实践。
在实践中,临床会诊的文档记录仍然是一项挑战,而且缺乏有关药学文档记录最佳实践的文献。为了给学术药学诊所的记录实践提供信息,UBC 药剂师诊所(诊所)实施了一项质量保证(QA)计划。该质量保证计划的目标是确定诊所药剂师在记录过程中存在哪些促进因素和障碍,并提高会诊记录的书写效率。第一阶段开展了一项在线调查,以评估每位药剂师在基线时的记录实践。第 2 阶段实施了可提高这些技能的新干预措施。主要引入了五项干预措施:1) 经修订的会诊记录模板;2) 文件 "核对表";3) 文件 "决策树";4) 临床文件指南;5) 文件同行反馈研讨会。在第 3 阶段,药剂师在 10 个月后重新回答了相同的调查问题。这样就可以直接比较干预前后的文档记录实践和技能。干预后,药剂师完成记录的时间缩短了近 14 分钟。修订后的笔记结构使模板使用率从 37% 提高到 100%。此外,在采取干预措施之前,大多数药剂师认为撰写会诊记录是日常工作流程中最繁重的工作。干预后,药剂师感觉到的负担程度明显减轻。这些发现可用于指导学生如何学习记录,并提高团队或初级医疗机构中药剂师的记录质量。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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