The medication chart as an integral tool in the pharmaceutical care plan

Aim: To develop a practical guide for pharmacists for the provision of clinical pharmacy services that would: 1. facilitate the delivery of a uniform standard of care; and 2. enhance communication between pharmacists and other members of the medication team. Method: A generic pharmaceutical care plan based on the'SHPA Standards of Practice for Clinical Pharmacy' was developed as an appropriate framework for the model. The plan is outcome oriented. It uses the patient's medication chart to document clinical information and activities and follows the patient from admission to discharge. The medication chart was chosen as the medium for documenting pharmaceutical care following a survey of the medical staff. Previously this information was recorded in patient profiles in individual pharmacists' ward folders. Results: Major outcomes included a change in clinical practice, improved discharge planning, visibility of the pharmacists' contribution to patient care, and an increase in the pharmacists' profile within the hospital. The plan also proved to be a useful tool for performance management and education purposes, and was well accepted by pharmacists. Conclusion: A formalised pharmaceutical care plan is a practical and efficient model for providing and documenting clinical pharmacy services. Using the medication chart as the medium for documenting clinical services supports continuity of care in the hospital, improves productivity and streamlines the discharge process. (author abstract)