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Documenting pharmaceutical care: creating a standard

B R Canaday1, P C Yarborough

  • 1Division of Pharmacy Practice, School of Pharmacy, University of North Carolina, Chapel Hill.

The Annals of Pharmacotherapy
|November 1, 1994
PubMed
Summary
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Pharmacy documentation lacks a standard approach. A proposed model offers a systematized method for patient pharmacotherapy evaluation, improving care continuity and communication across all practice settings.

Area of Science:

  • Pharmaceutical Sciences
  • Health Services Research

Background:

  • Current pharmacy practice lacks a standardized, systematized method for documenting patient pharmacotherapy.
  • Existing documentation approaches are fragmented and not universally applicable across diverse pharmacy settings.

Purpose of the Study:

  • To identify the need for a standardized documentation system for patient pharmacotherapy.
  • To propose a practical model for documenting pharmacotherapy evaluations in all pharmacy practice settings.

Main Methods:

  • Conducted a MEDLINE literature search.
  • Assessed current pharmacy documentation practices.
  • Reviewed existing methodologies for pharmacotherapy evaluation and documentation.

Main Results:

Related Experiment Videos

  • A universally accepted, standardized approach to documenting patient pharmacotherapy evaluation is currently absent in pharmacy.
  • A proposed model adapts the Subjective-Objective-Assessment-Plan (SOAP) system for pharmacy's unique documentation needs.

Conclusions:

  • The proposed documentation model provides a manageable format for pharmaceutical care concepts.
  • This standardized approach facilitates continuity of care, interprofessional communication, and data analysis for demonstrating service value.
  • The model serves as a foundation for establishing documentation standards in pharmacy practice.