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

Area of Science:

• Pharmacy Practice
• Clinical Documentation
• Quality Improvement

Background:

• Clinical encounter documentation is a persistent challenge in pharmacy practice.
• Limited literature exists on best practices for documentation in pharmacy settings.
• Academic pharmacy clinics require efficient and effective documentation strategies.

Purpose of the Study:

• To identify facilitators and barriers to documentation for pharmacists.
• To enhance the efficiency of consultation note writing.
• To inform documentation best practices at an academic pharmacy clinic.

Main Methods:

• A quality assurance initiative involving a three-phase approach.
• Baseline assessment via online survey of pharmacist documentation practices.
• Implementation of interventions including revised templates, checklists, decision trees, guides, and peer-feedback workshops.

Main Results:

• Pharmacists reduced note completion time by approximately 14 minutes post-intervention.
• Template usage increased from 37% to 100% after implementing revised note structures.
• Perceived burden of writing consultation notes significantly decreased.

Conclusions:

• Interventions effectively improved the efficiency and reduced the burden of clinical documentation for pharmacists.
• Findings can guide pharmacy education on documentation skills.
• Enhanced documentation practices can benefit team-based and primary care settings.