Identification of essential elements in the documentation of pharmacist-provided care

J Am Pharm Assoc (Wash). 2003 Jan-Feb;43(1):41-7; quiz 48-9.

Abstract

Objectives: [corrected] To develop guidelines for the documentation elements that need to be included in any record of pharmacist-provided care to allow the quality of the care to be assessed and to describe the use of these guidelines to improve the quality of pharmacist documentation.

Design: An initial list of 85 potential documentation elements, developed through a review of the literature, was validated by a group of pharmacy practitioners. Then, through three rounds of a Delphi process and a group meeting, a panel of experts reached consensus on a refined list of 27 documentation data elements.

Results: The documentation elements were formatted into a one-page Tool for Evaluation of Documentation (TED). The TED is a checklist for assessing the completeness of the documentation of pharmacist-provided care.

Conclusion: The TED and the consensus-building methodology used in the development of this tool can serve as cornerstones of a quality assessment process for documentation of pharmacist-provided care, enable further assessment of the quality of care, and, ultimately, be used to measure the impact of pharmacist-provided care on patient outcomes. Our results should provide guidance both to pharmacists providing care and to organizations that assess the quality of that care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Delphi Technique
  • Documentation*
  • Humans
  • Pharmaceutical Services / standards*
  • Practice Guidelines as Topic
  • Quality Assurance, Health Care / methods*
  • United States