How to professionally document clinical interventions in your clinical pharmacy department.

For this reason, you have to document your daily work. also to know where you are standing now, and closely watch your progress.

Let's see how to do it professionally through the following tips.

I. Write your daily clinical pharmacy interventions in a hard copy sheet (Paper sheet).

1- Day by day documentation is needed.

2- Paper sheet needs to provide spaces to write the following:

• Patient name.

• MRN (medical record number).

• Unit (eg. ICU, CCU, PICU, NICU, INP, etc).

• Date of admission.

• RDP (related drug problem).

• Type of intervention and your specific recommendation as a clinical pharmacist.

• Physician response (eg. accepted, rejected, hold, no action taken).

II. Collect the documented data from hard copy sheets, and document that collected data in another soft copy sheet (Excel Sheet).

1- Sheet needs to provide spaces to write the following:

• Patient Name.

• MRN (medical record number).

• Unit (eg. ICU, CCU, PICU, NICU, INP, etc).

• Date of intervention.

• Type of intervention (explained below).

• Related to (medication name).

• Physician response (eg. accepted, rejected, hold, no action taken).

• Clinical pharmacist name (to evaluate staff clinical pharmacists).

• Notes (eg. reason for rejection, lab value number, etc)

• Physician Name (to appreciate if always responsive, or to solve the problem if there is resistance or carelessness)

2- Collect and analyze the soft copy data monthly.

III. Types of clinical pharmacy interventions.

• Antibiotic Modification.

• Improper Drug Selection.

• Dose Adjustment.

• Improper Frequency.

• Duplication.

• Untreated Indication.

• Treatment Without Indication.

• Improper Dose.

• Lab Monitoring.

• Drug Interaction.

• Dose Modification.

IV. Calculate numbers and percentages.

1- Physician response based statistics.

To know and evaluate the following:

• High percentage of (accepted/total) means that clinical pharmacists have strong evidence and good communication skills to convince physicians.

• High percentage of (rejected/total) means that either clinical pharmacists have weak evidence, bad communication skills, or there is resistance from physicians, that could be solved by training and discussion to get these problems solved.

• High percentage of (no action taken/total) means that the problem here is carelessness, that could be solved by training and discussion to get this problem solved.

2- Unit based statistics.

• To determine which unit lacks the services of clinical pharmacy practice, and provide it with.

3- Intervention based statistics.

• To determine which problem is frequently repeated, then it could be easily solved. (eg. when improper dose intervention is frequently repeated, that means it's time for training on dose calculations through lectures).

4- Medication based statistics.

• To determine which medications are frequently repeated, then an educational sessions about these drugs.

V. Make visual charts.

To make it easier to read and understand. That visual charts should show the following:

• Numbers

• Percentages

I hope you find these tips useful, Questions are more than welcomed, Just write yours in a comment.

at the end, I'd like to say to every Senior or junior pharmacist, to every fresh graduate pharmacist, and to every pharmacy student...

Always Remember To Be The Good Pharmacist You Wish You See.