Focus on Pharmacy Documentation
Once upon time, the pharmacists in hospital would document on paper. The paper medication chart, the yellow paper Medication Management Plan, the paper discharge prescription. You could find the pharmacist’s green (or red or purple) pen annotations all over the place with helpful information to assist medication management. In fact we were affectionately (we hope) known for our little pen annotations. However, since the implementation of eMR and eMeds the pharmacist documentation has been streamlined and standardised. Standard templates are used to improve quality and consistency of documentation. In the eMR you will see several types of documentation from the pharmacists however the following three are the most common: 1. Medication Reconciliation on Admission (Medication Management Plan MMP) This is used to document the patient’s med ication history, medication reconciliation and any issues identified which need addressing by the treating team. It allows documentation of the sources used to obtain the medication history as well as the community care providers and use of specific dose administration aids. Pharmacists will include an individualised pharmacy plan for a patient’s discharge. 2. Pharmacy Progress Note This is used to document most pharmacy interactions or interventions outside of the main medication management plan. It can be subtitled to make it clear the subject of the progress note. The most common is subtitled Pharmacy Progress Note - Pharmacy Discharge Reconciliation. This is used to document the review of a patient’s discha rge medication prescription. It documents the discharge medication reconciliation and any issues that need addressing by the treating team. It documents the medication supply and education provided to the patient as well as any communications such as with community pharmacies or residential aged care facilities. 3. AMS Review Form -text Antimicrobial Stewardship review This is used to document interventions and recommendations by the Antimicrobial Stewardship team, usually the Antimicrobial Stewardship pharmacist, including the appropriateness and compliance to guidelines for the medication/s charted and a review date for the therapy recommended. In addition to documentation in the main eMR, the pharmacists can make minor comments in eMeds to individual medication orders and this can be seen on the MAR in the comments section.
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