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Journal de Pharmacie Clinique

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Registration of pharmaceutical intervention in patient health record Volume 35, issue 1, Mars 2016

Authors
Unité de recherche en pratique pharmaceutique, Département de pharmacie, CHU Sainte-Justine, Montréal, Québec, Canada
* Tirés à part

For decades, we recognize the importance of written documentation for pharmaceutical interventions, although a significant proportion of the pharmacist's clinical activity is based on verbal communication. The aim of our study was to evaluate the registration of pharmaceutical interventions in our center. First, by extracting data from pharmacists’ logbooks. Then, by realizing an audit in order to quantify and assess the quality of pharmaceutical interventions registration in patient health records. Between April 1 1997 and March 31 2014, 29,555 ± 13,034 pharmaceutical interventions were recorded per year. It steadily increased and reached to 55,200 pharmaceutical interventions in 2014-2015, out of which 21% (11,592) were recorded in the patient health record. During our audit, 58.4% (73/125) of patients had at least a written note of a pharmacist resulting from pharmaceutical intervention in their health record. A total of 337 notes were identified corresponding to 433 pharmaceutical interventions. Each intervention is focused on one or more of the following: drug therapy monitoring, therapy modification, patient advice, management of drug interaction, best possible medication… Furthermore, our data showed a high rate of compliance with the interventions writing rules. Our study suggests that a higher number of interventions are recorded in the patient health record than what is reported in the logbook. In our center, pharmacists perform many interventions per year, and register some of them in the patient health record. However, due to the legal and normative framework and continuity of care it is necessary to increase the proportion of written notes. Indeed, only written notes guarantee continuity of care and accountability of clinicians.