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Related Experiment Videos

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

J D Huntress1, C J Possidente, D J Harry

  • 1Rochester General Hospital, Department of Pharmacy, NY 14621.

American Journal of Hospital Pharmacy
|December 1, 1990
PubMed
Summary
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A new coding system allows pharmacists to document clinical interventions in electronic health records. This system successfully captured interventions, with physicians accepting over 85% of recommendations.

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.

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  • 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.