Clinical documentation for patient care: Models, concepts, and liability considerations for pharmacists

Zierler-Brown, Seena; Brown, Timothy R.; Chen, David; Blackburn, Robert Wayne

doi:10.2146/ajhp060682

Cited by 58 publications

(61 citation statements)

References 9 publications

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“…7 Likewise, pharmacy schools and educators use various models to teach documentation of patient encounters, most often using the SOAP (Subjective, Objective, Assessment, Plan) structure, but in other cases TITRS (Title, Introduction, Text, Recommendation, Signature) and FARM (Findings, Assessment, Recommendations or Resolutions, Management). 8 Documentation of patient encounters using a standardized process such as a SOAP note (a critical interprofessional communication tool in the era of electronic health records), is generally considered an essential competency for pharmacists and students. 9,10 This manuscript proposes that this portion of the pharmacy curricula will be one of the easiest places to begin integration of teaching the PPCP.…”

Section: Applying Ppcp In Teachingmentioning

confidence: 99%

Implementing the Pharmacists’ Patient Care Process at a Public Pharmacy School

Cooley

Lee

2018

American Journal of Pharmaceutical Education

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The Joint Commission of Pharmacy Practitioners has provided the profession of pharmacy a patientcentered care model known as the Pharmacists' Patient Care Process (PPCP). This process will serve to provide consistency throughout the profession as it becomes incorporated throughout pharmacy practice and education. A description of the early stages of implementing the PPCP at one public college of pharmacy provides insights into opportunities for education and assessment.

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Section: Applying Ppcp In Teachingmentioning

confidence: 99%

Implementing the Pharmacists’ Patient Care Process at a Public Pharmacy School

Cooley

Lee

2018

American Journal of Pharmaceutical Education

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“…5,6 These other health care professionals are also typically situated in hospital and pharmacy settings, which are quite different from the usual collegiate and secondary school athletic training environments. 5,7 Even facilities, budgets, staffing, and administrative structures may vary within the same type of athletic training practice setting, such as secondary schools. 8 Quality patient care documentation by health care professionals is important for both clinicians and patients.…”

Section: à7mentioning

confidence: 99%

“…8 Quality patient care documentation by health care professionals is important for both clinicians and patients. 7,9 Although many health care professionals document patient care because of legal obligations, 7 physicians, nurses, and pharmacists have noted additional benefits of documenting. 5,6 Effective documentation facilitates communication among health care professionals, enabling continuity of care for patients.…”

Section: à7mentioning

confidence: 99%

“…5,6 Effective documentation facilitates communication among health care professionals, enabling continuity of care for patients. 5,7 Clinicians can also use documentation to evaluate the effectiveness of their patient care, which can then be used to demonstrate ATs' value and worth as health care professionals. 9 Similar to other health care professionals, ATs have a professional responsibility to document patient care.…”

Section: à7mentioning

confidence: 99%

“…Zierler-Brown et al 7 pointed out that, if a patient interaction is not documented, the current legal system assumes that the interaction never occurred. Thoroughly documenting patient interactions from start to finish, including subjective and objective patient information, clinician rationale for treatment decisions, referrals, and other information recommended by professional guidelines and state practice acts, ensures that patient care is performed according to the standards of care.…”

Section: Reasons For Documenting Patient Carementioning

confidence: 99%

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Athletic Trainers' Reasons for and Mechanics of Documenting Patient Care: A Report From the Athletic Training Practice-Based Research Network

Nottingham

Lam

Kasamatsu

et al. 2017

Journal of Athletic Training

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Context: Documenting patient care is an important responsibility of athletic trainers (ATs). However, little is known about ATs' reasons for documenting patient care and the mechanics of completing documentation tasks. Objective: To understand ATs' perceptions about reasons for and the mechanics of patient care documentation. Design: Qualitative study. Setting: Individual telephone interviews with Athletic Training Practice-Based Research Network members. Patients or Other Participants: Ten ATs employed in the secondary school setting (age = 32.6 ± 11.4 years, athletic training experience = 7.1 ± 7.8 years) were recruited using a criterion-based sampling technique. Participants were Athletic Training Practice-Based Research Network members who used the Clinical Outcomes Research Education for Athletic Trainers electronic medical record system and practiced in 6 states. Data Collection and Analysis: We used the consensual qualitative research tradition. One investigator conducted individual telephone interviews with each participant. Data collection was considered complete after the research team determined that data saturation was reached. Interviews were transcribed verbatim and independently analyzed by 4 research team members following the process of open, axial, and selective coding. After independently categorizing interview responses into categories and themes, the members of the research team developed a consensus codebook, reanalyzed all interviews, and came to a final agreement on the findings. Trustworthiness was established through multiple-analyst triangulation and member checking. Results: Participants identified 3 reasons for documenting patient care: communication, monitoring patient care, and legal implications. Four subcategories emerged from the mechanics-of-documentation theme: location, time of day, length of time, and criteria for documenting. The ATs described different criteria for documenting patient care, ranging from documenting every injury in the same manner to documenting time-loss and follow-up injuries differently. Conclusions: Whereas ATs recognized individual mechanisms that enabled them to document patient care, they may need more guidance on the appropriate criteria for documenting various patient care encounters and strategies to help them document more effectively.

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Is a FASTHUG enough? Going beyond mnemonics for the next generation of pharmacy learners

Peters

Jarrell

Johnson

et al. 2023

J Am Coll Clin Pharm

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Mnemonic devices are acronyms, abbreviations, or other learning tools that have been used for decades to memorize basic concepts. They are ubiquitous in teaching settings, including among intensive care unit (ICU) pharmacists, where the mnemonic FASTHUG (Feeding, Analgesia/Sedation, Thromboembolic prophylaxis, Head of bed, Ulcer prophylaxis, Glucose) is commonly cited. FASTHUG has existed since 2005 and serves as a reminder for key components of care for a critically ill patient. Due to the popularity of this acronym, multiple iterations have been created, where creative authors update, change, and/or add to the mnemonic. While FASTHUG is a unique learning tool with strengths for the entire care team, it has clear pitfalls when used in the pharmacy learning setting (i.e., during advanced practice rotations or for a postgraduate year 1 resident). This has led to the implementation of distinct mnemonic tools which are more specific to pharmacy interventions. The result is a myriad of published tools available for preceptors with limited data supporting their use in practice. A thorough understanding of the educational benefits of mnemonic devices paired with a recognition of their pitfalls can improve learning experiences. This review is designed to help preceptors understand the role of mnemonic devices and deploy them strategically for pharmacy learners. Furthermore, current pharmacy learners have different needs and characteristics when compared with other generations. This may alter the current students' level of comfort with utilizing mnemonics. Alternative teaching strategies that may be more beneficial for today's learners include technology and media utilization, scenario‐based discussions, and hands‐on application of mnemonics. Pharmacists who understand these variables can optimize their rotations and improve the learning experience for both themselves and their learners.

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Clinical documentation for patient care: Models, concepts, and liability considerations for pharmacists

Cited by 58 publications

References 9 publications

Implementing the Pharmacists’ Patient Care Process at a Public Pharmacy School

Implementing the Pharmacists’ Patient Care Process at a Public Pharmacy School

Athletic Trainers' Reasons for and Mechanics of Documenting Patient Care: A Report From the Athletic Training Practice-Based Research Network

Is a FASTHUG enough? Going beyond mnemonics for the next generation of pharmacy learners

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