Documentation of patient care services in a community pharmacy setting

To assess the types of patient care documentation systems currently being used by community pharmacists and determine the preferred characteristics of an ideal patient care documentation system.

Mailed survey.

United States.

One pharmacist from each of 125 targeted community pharmacies.

Survey mailed in February 2003, followed by a second mailing to nonrespondents in March 2003.

Responses to survey items about (1) patient care services provided at the pharmacy, (2) characteristics of the current documentation system, and (3) characteristics of an ideal documentation system.

A total of 48 usable responses were received from 106 pharmacies to which surveys were delivered (45.3%). Independent pharmacies accounted for 50% of survey respondents. More than 80% of respondents were providing patient screening or management services associated with a chronic disease such as diabetes, hypertension, or dyslipidemia. Approximately 54% of the pharmacists were using a paper documentation system. However, challenges identified with a paper system included documentation time, retrieval of patient data, tracking patient outcomes, and storage. Respondents indicated that an ideal documentation system would be comprehensive, easy and efficient to use, and affordable.

Pharmacists recognize the importance of documenting patient care services. While the majority of respondents are using paper charts to document patient care services, computerized systems appear to offer advantages over paper charts. This information offers community pharmacists a summary of previous experiences and a starting point when trying to identify or modify a documentation system that would better meet the pharmacies' needs.