Documentation of patient care services in a community pharmacy setting. 2006

Kelly A Brock, and Kristin A Casper, and Tara R Green, and Craig A Pedersen
College of Pharmacy, Western University of Health Sciences, Pomona, California, USA.

OBJECTIVE To assess the types of patient care documentation systems currently being used by community pharmacists and determine the preferred characteristics of an ideal patient care documentation system. METHODS Mailed survey. METHODS United States. METHODS One pharmacist from each of 125 targeted community pharmacies. METHODS Survey mailed in February 2003, followed by a second mailing to nonrespondents in March 2003. METHODS Responses to survey items about (1) patient care services provided at the pharmacy, (2) characteristics of the current documentation system, and (3) characteristics of an ideal documentation system. RESULTS A total of 48 usable responses were received from 106 pharmacies to which surveys were delivered (45.3%). Independent pharmacies accounted for 50% of survey respondents. More than 80% of respondents were providing patient screening or management services associated with a chronic disease such as diabetes, hypertension, or dyslipidemia. Approximately 54% of the pharmacists were using a paper documentation system. However, challenges identified with a paper system included documentation time, retrieval of patient data, tracking patient outcomes, and storage. Respondents indicated that an ideal documentation system would be comprehensive, easy and efficient to use, and affordable. CONCLUSIONS Pharmacists recognize the importance of documenting patient care services. While the majority of respondents are using paper charts to document patient care services, computerized systems appear to offer advantages over paper charts. This information offers community pharmacists a summary of previous experiences and a starting point when trying to identify or modify a documentation system that would better meet the pharmacies' needs.

UI MeSH Term Description Entries
D011314 Preventive Health Services Services designed for HEALTH PROMOTION. Health Services, Preventive,Preventive Health,Preventive Health Care,Preventive Health Programs,Preventive Programs,Services, Preventive Health,Care, Preventive Health,Health Care, Preventive,Health Program, Preventive,Health Programs, Preventive,Health Service, Preventive,Health, Preventive,Preventive Health Program,Preventive Health Service,Preventive Program,Program, Preventive,Program, Preventive Health,Programs, Preventive,Programs, Preventive Health,Service, Preventive Health
D003157 Community Pharmacy Services Total pharmaceutical services provided to the public through community pharmacies. Community Pharmaceutic Services,Community Pharmaceutical Services,Pharmaceutic Services, Community,Pharmaceutical Service, Community,Pharmaceutical Services, Community,Pharmacy Services, Community,Service, Community Pharmaceutic,Service, Community Pharmaceutical,Service, Community Pharmacy,Services, Community Pharmaceutic,Services, Community Pharmaceutical,Services, Community Pharmacy,Community Pharmaceutic Service,Community Pharmaceutical Service,Community Pharmacy Service,Pharmaceutic Service, Community,Pharmacy Service, Community
D004282 Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information. Documentations
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D016347 Medical Records Systems, Computerized Computer-based systems for input, storage, display, retrieval, and printing of information contained in a patient's medical record. Automated Medical Records Systems,Computerized Medical Records Systems,Automated Medical Record System,Automated Medical Record Systems,Automated Medical Records System,Computerized Medical Record System,Computerized Medical Record Systems,Computerized Medical Records System,Computerized Patient Medical Records,Medical Record System, Automated,Medical Record System, Computerized,Medical Record Systems, Automated,Medical Record Systems, Computerized,Medical Records System, Automated,Medical Records System, Computerized,Medical Records Systems, Automated
D017050 Episode of Care An interval of care by a health care facility or provider for a specific medical problem or condition. It may be continuous or it may consist of a series of intervals marked by one or more brief separations from care, and can also identify the sequence of care (e.g., emergency, inpatient, outpatient), thus serving as one measure of health care provided. Patient Care Episodes,Episodes of Care,Care Episode,Care Episodes,Episode, Patient Care,Episodes, Patient Care,Patient Care Episode
D019468 Disease Management A broad approach to appropriate coordination of the entire disease treatment process that often involves shifting away from more expensive inpatient and acute care to areas such as preventive medicine, patient counseling and education, and outpatient care. This concept includes implications of appropriate versus inappropriate therapy on the overall cost and clinical outcome of a particular disease. (From Hosp Pharm 1995 Jul;30(7):596) Disease Managements,Management, Disease,Managements, Disease

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