title: Quality of pharmacists' documentations in patients' medical records.
abstract: Training pharmacists to appropriately document patient-specific problems and recommendations in patients' medical records and subsequent monitoring of pharmacist-written documentation are described. The medical staff of a tertiary care teaching hospital recommended that pharmacists be allowed to write in the permanent portion of patients' medical records. A six-month pilot program was approved to train pharmacists in writing chart notes. Notes would be assessed according to the following criteria: necessity (i.e., a chart note was the appropriate means of communication), clarity, legibility, completeness, correct format, and lack of judgmental language. Initial training was by physicians from the pharmacy and therapeutics committee, with more extensive training by a committee composed of clinical and administrative pharmacists. After training ended, each pharmacist's first few notes were reviewed by a member of the pharmacy committee. The quality of pharmacist-written notes is reviewed quarterly. The first quarterly evaluation and another review 1 1/2 years later showed that all pharmacist notes met all of the established criteria. A multidisciplinary approach was effective in training pharmacists to document interventions appropriately in patients' permanent records. Ongoing monitoring ensures the continuing quality of such documentation.
authors.affiliation: Department of Pharmacy Services, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: C F
authors.initials: CF
authors.lastname: Lacy
authors.forename: F G
authors.initials: FG
authors.lastname: Saya
authors.forename: R R
authors.initials: RR
authors.lastname: Shane
mesh_terms: D004282:Documentation / Q000592:standards*; D004513:Education, Pharmacy, Continuing; D006746:Hospital Bed Capacity, 500 and over; D006784:Hospitals, Teaching; D007318:Inservice Training; D015141:Los Angeles; D008499:Medical Records / Q000592:standards*; D010607:Pharmacy Service, Hospital / Q000458:organization & administration / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000458:organization & administration