Why pharmacists can struggle without documentation

PDL has highlighted the importance of documentation, citing two case scenarios where failing to document could have significant impact

In its latest newsletter, PDL highlights that adequate documentation of interaction with patients is an essential part of the provision of a clinical pharmacy service.

“Pharmacists are challenged with an increase in the complexity of pharmaceutical services as well as the volume of prescriptions and patient interactions,” writes Katrina Short, NSW PDL Local Advisory Committee Member.

“It can often be a struggle to remember a patient episode from last week, let alone several months ago.

“However sometimes we do need to recall our actions regarding a specific episode and in those instances we rely on our documentation of the incident.”

As well as patient-specific information such as allergies, documentation should also include the recording of counselling episodes and professional actions; clinical interventions; and incidents and errors.

In the first case scenario used by PDL, a patient has been started on the high-risk medicine Apixaban. The pharmacist counselled the patient and provided a CMI, but did not document the episode.

Several weeks later, a family member contacts the pharmacy and says that the patient is in hospital with a GI bleed, claiming that the pharmacist’s counselling was not adequate and stating that they plan to make an official complaint to AHPRA.

The pharmacist only “vaguely” remembers the interaction with the patient and believes they provided counselling and the CMI, but in the absence of any documentation had no adequate proof that adequate counselling had indeed happened.

Documentation is also important in dealings with prescribers, PDL points out.

In its second case scenario, a middle-aged man with a history of asthma presents with a script for Propranolol to prevent migraines.

The pharmacist contacts the prescriber to suggest that a Triptan could be safer, but the doctor insists on Propranolol and the pharmacists dispenses the medication.

“A couple of months later the patient returns and explains that after taking the Propranolol, he had an acute asthma attack and was hospitalised, missing an important international business trip. He has now decided to sue both the prescriber and the pharmacist.”

Again, with no documentation of the episode, the pharmacist will struggle to defend their actions, PDL observes.

It encourages PDL members to utilise PDL’s Guide to Good Dispensing, and contact its professional officers immediately in the case of a dispensing error, referring to their documentation.

Incidents should be recorded according to workplace protocols and if an official complaint is made, details of the incident will be available, “no matter how inconsequential it may seem at the time”.

PDL encourages members to call it on 1300 854 838 if this topic raises any concerns; it offers 24/7 access to Professional Officers for advice and incident support.

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