Documenting pharmacists' interventions on a hospital's mainframe computer system

Area of Science:

• Health Informatics
• Clinical Pharmacy
• Health Information Systems

Background:

• Pharmacists play a crucial role in optimizing patient care through clinical interventions.
• Documenting these interventions is essential for quality improvement and demonstrating value.
• Existing methods for documentation may be inefficient or lack integration with electronic patient records.

Purpose of the Study:

• To describe the development and implementation of a novel coding system for documenting pharmacist clinical interventions.
• To integrate this documentation seamlessly into the hospital's computerized patient records.
• To evaluate the system's effectiveness in capturing and reporting pharmacist interventions.

Main Methods:

• A specific code was developed to summarize pharmacist recommendations for entry into patient records.
• The code was integrated into the hospital's mainframe computer system, accessible via terminals.
• An in-house computer program was created for generating daily reports on pharmacist interventions.

Main Results:

• During a 25-day study, 300 pharmacist interventions were documented.
• Physicians accepted 85.7% of pharmacist recommendations.
• An additional 6% of interventions originated from physician requests for pharmacist input.

Conclusions:

• The developed coding system effectively enables pharmacists to document clinical interventions within electronic patient records.
• This system facilitates the retrieval of valuable data for reviewing pharmacist services and drug-use guideline compliance.
• Implementation enhances the visibility and integration of pharmaceutical care within the hospital information system.