clinical note writing pharmacy department dale tucker, rph, bcps elizabeth cincotta, pharmd detroit...

Amount of detail may vary from site to site

Goals and Objectives

Goal: To orient the pharmacist to writing consistently accurate and clear notes in patient charts.

Objective: To give the pharmacist experience in note writing in the chart and have the notes formally reviewed in conjunction with pharmacokinetic and anticoagulation instruction.


Introduction

Why write notes?Note variations Pharmacokinetics Anticoagulation

Note types First notes Follow-up notes

Note etiquetteNote QAs


Why Write Notes?

Define/communicate issues

Discuss current and alternative therapies

Determine drug duration of therapy

Suggest drug changes

Inform about patient education or medication adherence history


Types of Notes

Pharmacokinetic notes

Anticoagulation notes

Patient education notes

Renal dosing notes

TPN notes

Other medication notes


General Breakdown of Notes

First notes Include pertinent

patient history Include reason for

consult Include related lab

values, vital signs, and culture results

Assess medication regimen

Make recommendations

Follow-up notes Assess duration of

therapy Update related lab

values and culture results

Assess medication regimen

Make recommendations


All First NotesSome sites may have a standardized sticker available

Date and timeHeader: Pharmacy Services or Anticoagulation Dosing Service, etc.Patient demographics (age, allergy status, height, weight) and historyMedications as appropriateReason for consult or indication for therapy being monitoredPertinent lab values (BUN/Cr, CBC, cultures, etc.) Plan and/or a recommendationSignature and pager number


Pharmacokinetic First Notes Some sites may have a standardized sticker available

Include patient’s temperature (Tmax, Tcurrent)On ICU and BMT units include I/OsInclude culture resultsInclude pharmacokinetic parameters for aminoglycoside drugsInclude desired goal levels and plan or need for monitoring levelsAddress any other antibiotics the patient is taking as per site requirementsIndicate that primary team is to monitor for signs/symptoms of nephrotoxicity or ototoxicity


Anticoagulation First Notes Some sites may have a standardized sticker available

Include baseline or most recent as well as current INR/PT and/or aPTT if possible

Assess potential drug and dietary interactions

Include target values for INR and/or aPTT

Indicate when to monitor next INR or aPTT

Address all anticoagulants the patient is taking

Indicate MD/RN to monitor for signs/symptoms of bleeding


All Follow-up Notes Some sites may have a standardized sticker available

Include reason for consult or indication for therapy being monitored Note: The reason for therapy may change and needs

to be evaluated with each note written, i.e., rule out pneumonia is not appropriate a week after the initial note

Indicate day of therapy and assess duration of therapyInclude updated pertinent lab values Include a plan and/or a recommendation


Pharmacokinetic F/U Notes Some sites may have a standardized sticker available

Include patient’s temperatureUpdate culture resultsReport any drug levels with an interpretation of them and/or a recommended actionIndicate the times of the levels with reference to the time the dose was givenOn ICU and BMT units include I/OsIndicate that primary team is to monitor for signs/symptoms of nephrotoxicity or ototoxicity


Anticoagulation F/U Notes Some sites may have a standardized sticker available

Include target values for INR and/or aPTT

Indicate the most recent CBC

Indicate plan for transition to oral warfarin such as DC heparin when INR at goal X2 days

Indicate primary team is to monitor for signs/symptoms of bleeding


Note the Common Threads

Always be organized and neat

Always include reason for the consult or indication for therapy being monitored

Always update any lab values or culture results

Always include a plan and/or a recommendation


“Political Correctness”

Use notes to communicate information pertinent to the care of the patientUse only approved abbreviations when writing orders or notesDo not argue a point in the notes: CALL THE PHYSICIANAvoid judgmental statementsNever write a note when emotionally upset


DMC: Unsafe AbbreviationsDO NOT USE Intended Meaning USE THIS INSTEAD

U or IU units Use “units” or “international units”

µg micrograms Use “mcg” or “micrograms”

Lack of leading zero (.5 mg)

0.5 mg Always use leading zeros when the dose is less than a whole unit

Use of trailing zero (5.0 mg)

5 mg Never use trailing zeros for doses expressed in whole numbers

TIW Three times a week Use “three times a week”

° symbol hours Use “hour, hr or hrs”

Q.D. Once daily Use “daily”

Q.O.D. Every other day Use “every other day”

MS, MSO4 , Mg SO4 Morphine sulfate or Magnesium sulfate

Use “morphine sulfate, magnesium sulfate”


Word Choices

Recommend When you are 100% sure of your

recommendation

Suggest When fairly certain of your decision

Consider When you are even slightly hesitant about

your recommendation


Word Choices

DON’T USE Toxic Supratherapeutic Above therapeutic

range Maximum High Bad Wrong

USE Above goal for this

patient and indication Not within desired

range for this patient


Word Choices

DON’T USE Subtherapeutic Below therapeutic

range Minimum Low Bad Wrong

USE Below goal for the

patient and indication Not within desired

range for this patient


Word Choices

DON’T USE Abbreviations for

terms (drug names, pharmacokinetic parameters) that are not approved by the hospital or that may have other explanations


Word Choices

DON’T USE Exact number for an

estimated value (i.e., CrCl=46ml/min)

USE Ranges (i.e., CrCl=40-

60ml/min) Approximately

36ml/min

Remember, calculations are an estimate!


Clinical Quality Assessment

To give a peer review of pharmacist communication in the chart and on the PMR

To evaluate the content of notes

To evaluate pharmacy monitoring record (PMR) for completeness

To compile data quarterly as a clinical quality indicator


Peer Reviewed Quality Assessment

Everyone who writes notes Has their notes evaluated by other clinical

pharmacists Is expected to evaluate and submit a QA of

other clinical pharmacist’s notes (~10/month) Submits QAs of pharmacist and non-pharmacist

orders when discrepancies are noted such as “U” written instead of “units”

NOTE: submit QA for correct notes, too!


QA Monitoring Form


In Conclusion

Be clear!

Be accurate!

Your notes are being read!

clinical note writing pharmacy department dale tucker, rph, bcps elizabeth cincotta, pharmd detroit...

Documents

clear notes

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patient charts

drug levels

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initial note

patient demographics

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