In the last couple of years, pharmacists have heard so much about the need to document what we do, about the importance of documentation and the urgent requirement for us to always put down on paper our interactions with patients. In various forums, pharmacists have been encouraged, challenged, I dare say even threatened with dire consequences if the skill of documentation is not imbibed, embraced and carried out on a consistent basis. Unfortunately, the story has not changed considerably. Processes to document the clinical activities and therapeutic interventions of pharmacists have been described extensively in the pharmacy literature, yet universal adoption of documentation throughout pharmacy practice remains inconsistent, incomplete, and misunderstood.
Documentation is important primarily to improve the quality of patient care. It serves as a record of the care provided and a history of the decisions made for a specific patient. This enhances future decisions made for the patient, serves as an effective method of communication between all the pharmacists who interact with the patient and provides the pharmacist with a basis of communicating with other health professionals involved in the care of the patient and when seeking reimbursement for services (where applicable). Documentation fulfils reimbursement requirements and helps the pharmacist manage risk by affording some legal protection in the event of malpractice or negligence. As the role of the pharmacists change, documentation provides a tool to identify and record the new activities of pharmacists. It also provides a method by which to begin to formally evaluate cost-benefit or cost-effectiveness of specific services. As registered NHIS providers, documentation is necessary in order to seek reimbursement for pharmaceutical care services provided. If pharmacists are to be paid for providing care, it is clear that they will be required to document those services and the outcomes of those services. Clear concise documentation will thus be essential.
There is an advert I love so much. It is about advertising. It says that, “Running a business without advertising it is like winking in the dark. You know what you are doing but nobody else does”. I believe that pharmacists interacting with patients without documenting it can be likened to this winking in the dark. You are unable to convince anybody that you are carrying out a service that you do not document. By the time you say you have a significant role in your community and you cannot produce hard (documentary) evidence of patients you have helped or healthcare practitioners you have assisted or money that you have saved to those that are qualified to check it, then you have failed in your duty.
Culled from Viewpoint, Nigerian Journal of Pharmacy (2013)
What are you views on documentation? In your view, how can it be easily integrated into services carried out in the pharmacy? Apart from those listed, what other uses can documentation be put to in the pharmacy? Is documentation equally important in all fields of pharmacy or only useful for the clinical areas