6

Chapter Outline

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1.	Introduction
2.	Documentation Styles
3.	Documentation Elements
4.	Communication Techniques
5.	Medical Liability and Auditing
6.	Chapter Summary
7.	References
8.	Additional Selected References
9.	Web Resources

Web Toolkit available at www.ashp.org/ambulatorypractice

Introduction

Regardless of your practice environment, you will need to use electronic and manual methods of documentation to communicate, exchange information, and educate patients, caregivers, and other health care professionals. Like other health care providers, you will primarily use the patient medical record (PMR) for documentation of patient care. Through efficient and comprehensive documentation you can (1) meet professional standards and legal requirements, (2) communicate with other health care professionals, (3) establish accountability for medication-related aspects of direct patient care, (4) strengthen transition and continuity of care, (5) create your record of critical thinking and judgment, (6) provide evidence of your value and workload allocation, (7) justify reimbursement for cognitive services, and (8) provide needed data for tracking of patient health outcomes.¹

Currently, industry-driven advances in technology are having a profound effect on how pharmacists document and are also creating new challenges. With the passage by Congress of the stimulus package (the American Recovery and Reinvestment Act, or ARRA), expansion of health information technology (HITCH) is now mandated by the U.S. government. ARRA budgeted approximately $150 billion for health care reform and close to $34 billion for health care provider adoption of HITCH and a nationwide health record system by 2014.² The most critical element to the e-health system is the electronic medical record (EMR) and the electronic health record (EHR). An EMR is a portal that shares relevant patient information among health care professionals. Likewise, it can perform as a patient scheduler and an intraoffice messaging system as well as assist with laboratory communications, e-prescribing, and billing processing. An EHR is an individual patient medical record digitized from many locations or sources, including the patient and family members. It can interface with evidenced-based treatment algorithms and protocols, outcomes reporting, and quality assurance and is synonymous with what is also called the patient medical record (PMR). An electronic personal health record (ePHR) can be created by patients, physicians, pharmacies, health systems, and other sources, but originates from a patient.²

An EMR and EHR can enhance provider communication in all health care settings. EMRs are primarily focused on physician and hospital-based practice, but there is potential for benefit in pharmacy practice with wider implementation. EMR adoption is predicted to bring the following patient and health care provider benefits: lower costs, quality care, improved reimbursement, enhanced productivity, efficiency, effectiveness, and communication.²

While the EMR has promise of advancing patient care and can be a resource to capture patient encounters, it is not without its challenges. This is especially true in the primary care setting due to the sheer number and small size of ambulatory organizations. Pharmacists practicing in the ambulatory patient care arena have historically used a modified SOAP (subjective, objective, assessment, plan) note format to document patient encounters, with sections expanded or omitted based on relevance to the practice and scope or service. It has been physician, and not pharmacist, work flow that has driven creation, adoption, and integration of most outpatient EMR and PMR applications. Consequently, it has been difficult to alter or adapt a physician-driven EMR to fit the work-flow dynamics of a pharmacist-provided visit in the ambulatory setting. For example, most templates that fit individual disease states have predetermined signs and symptoms that are consistent with a pharmacist’s visit, such as documentation of hypo- or hyperglycemic symptoms for diabetes; however, pharmacists do not perform eye exams routinely, thus documenting a normal eye exam would be inappropriate in the template. This is where the EMR can be tricky for the pharmacist because both are normally included in a diabetes visit template. This is important since it relates to payment for clinical services. Although pharmacists do not perform detailed physical exams, we do address complexity, such as multiple disease states, some aspects of review of systems (ROSs) and physical exams (PEs), monitoring, follow-up, and capturing of outcomes. Documentation on templates is designed to emphasize and ensure that the appropriate information is in place for billing using the correct evaluation and management service codes. Using a template that has incomplete sections or that can be billed inappropriately (physician services versus a midlevel provider services) could result in devastating financial and legal consequences for your organization. Depending on your EMR, investigate whether it has the ability to code and recognize language used in your template to populate other fields in the PMR to ensure correct billing for your services, to collect data related to your services, and to generate a list of patients for whom you have provided care. If not, you should consider a separate clinical pharmacy documentation system to capture your needed documentation. Optimally it should integrate in some form or manner with your organization’s EMR.

Because EMRs generally are not created with clinical pharmacy practice in mind, you may have already concluded it will be important for you to collaborate with your institutional information technology (IT) personnel as well as pharmacy management system (PMS) vendors as needed to develop the necessary technical integration solutions that incorporate your work flow and corresponding documentation requirements.² This seems like a straightforward solution; however, many IT personnel have no experience with pharmacists seeing patients in an ambulatory setting or with the details of how we document, so they may be unwilling or lack sufficient knowledge to build a special area for a pharmacy visit within the adopted EMR. This can be further complicated by the fact that not all EMRs are created equally, and the adopted EMR may require a major system overhaul or significant financial outlay to accommodate your clinical services. You should be prepared to educate IT personnel on how you document your patient encounters, such as the need for a universal template for all pharmacotherapy-based visits and specific disease-state templates (e.g., diabetes or anticoagulation). An existing physician template may be used with minor or no alterations.

How do you know which type of templates work for you within an EMR? Just like other challenges in the pharmacy world you will need to research and investigate the functionality of the proposed or current EMR at your site. Visit the EMR vendor web page and familiarize yourself with the advantages and disadvantages of the application and whether the system can address the needs of midlevel providers such as the clinical pharmacist. Reviewing articles and attending lecture series as well as professional meetings may help, but usually it requires your review of your particular system to solidify its application to your services. One resource is the American Medical Association’s online bookstore.³ Currently, there are several books available that discuss types of EMRs, as well as incorporation and maintenance of the systems. (AMA web site) Granted, pharmacists rarely have a vote in the decision regarding which system is purchased for outpatient services, but such EMR resources can educate you on which systems allow specialization and customization and which are more restrictive in adapting to midlevel provider patient care services.

Once you understand your EMR’s flexibility and how your services will integrate into the EMR system, you can begin to create or adapt your current manual patient care notes to an electronic template format. The majority of EMRs do use a SOAP-based format, but it may appear unrecognizable because many systems follow a point-and-click process rather than use free text for documenting. No matter which format, you will have to integrate your documentation within the systematic approach designed by the EMR’s manufacturer. It is imperative that your documentation work flow be developed with your input and feedback to ensure the documentation process is efficient, easy to use, synergistic with the flow of the patient visit, and captures all the needed information. If the process is not scrutinized thoroughly, you may find yourself inefficiently jumping around the screen or having to type a large amount within your template; this leads to less time spent seeing patients and ultimately decreasing productivity and reducing reimbursement, which affects the viability of your practice.

One solution is to critically assess work flow with IT assistance to create an electronic template that is geared toward practice functions (pre-visit information gathering, visit documentation, orders you are able to execute, and billing) as well as the type of patient care visits you encountered. One example is an anticoagulation visit in which the international normalized ratio (INR) is obtained by the nursing staff while they are doing vitals and preparing the patient room for the office visit. You may then enter the room to complete your visit with information already entered into the electronic note. Alternatively, you, a resident, or your advanced practice clerkship student could be responsible for performing vitals, point-of-care testing, and the interview. The work flow and thus the note would be different. The key is to create your template around the structure and flow of your patient visit. No matter which work flow and template is incorporated, your note should always contain the following elements:

• time of arrival and departure
  
• chief complaint
  
• history of present illness
  
• past medical history
  
• allergies
  
• social history
  
• family history
  
• appropriate referrals
  
• labs
  
• medication reconciliation
  
• assessment and plan

(Example Documentation Elements for EMR/PMR)

Once you have your work flow outlined and templates designed, the next step is to ensure the security of your system. The overall security will be created and implemented by the IT department; however if the setting is an experiential training site, you will need to create security measures that limit the access of your pharmacy students. For a thorough experience, students will need access to the EMR with their own log-on information; however, their integration must be limited so they cannot “complete” an encounter note without your preceptor’s electronic signature.

Another consideration is integrating pharmacy residents that are completing training at your institution into your documentation process. As pharmacy residents are licensed pharmacists and generally should receive greater autonomy, you may wish to create an electronic preceptor section within the encounter note that allows the preceptor to add addenda and cosign the resident’s completed note. This allows supervision by the preceptor, a level of autonomy for residents, and billing for the visit, since technically the precepting pharmacist is the collaborating midlevel provider, not the pharmacy resident.

Despite the many challenges, transitioning to an EMR and computerized provider order entry (CPOE) is the future and a requirement under new Medicare Part D regulations that were effective in 2009. Technological advancement certainly facilitates generation and transfer of documentation and holds much promise to improve patient safety, although many concerns still exist, such as access to data (storage) and patient confidentiality. The American Society of Health-System Pharmacists (ASHP) has an investment to “increase the extent to which health systems apply technology effectively to improve the safety of medication use.” ASHP has identified several targets to aid in goal achievement, including enhanced use of CPOE and EMRs, along with enhancement of information access and communication across the health care continuum. Since 2005, pharmacists in 19% of health systems transfer information to promote seamless care of patients with complex medication regimens. ASHP strives to increase integration of technology as the new pharmacy practice model is defined and adopted by practice sites.^2,4

Documentation Styles

Whether the information is typed or written into a PMR, the documentation of a clinical interview should provide (1) what happened, (2) to whom, (3) who made it happen or the cause of the event, (4) occurrence, (5) rationale for why it occurred, and (6) outcome of action.^1,5–9 A survey among community-based pharmacists identified the following primary characteristics of ideal documentation practices: comprehensiveness, affordable cost, time efficiency, ease of use, and ability to generate patient reports.⁵ Additionally, with our improved understanding of the perils associated with patient transitions of care, communication and coordination of care documentation should be added to this list. Several documentation styles can and have been adapted to record pharmacist encounters, including unstructured notes, semistructured notes, and systematic records, all possible in written documentation and growing in popularity within EMR formats. No matter the format and media, documentation should be

• clear,
  
• concise,
  
• legible,
  
• nonjudgmental,
  
• patient focused,
  
• standardized, and
  
• confidential.^1,6–8

The most common format used in the medical system is systematic documentation, which includes SOAP, TITRS (title, introduction, text, recommendation, signature), and FARM (findings, assessment, recommendations or resolutions, and management). Other examples of structured formats include drug-related problem, rationale, plan (DRP); data, assessment, and plan (DAP); and drug-related problem, data, assessment, and plan (DDAP). TITRS is an assessment approach, and FARM places importance on monitoring, but these formats are not common among pharmacists’ documentation and therefore are not discussed in greater detail. The SOAP note is an interventionist approach and considered the standard for most if not all health care providers, including pharmacists.^1,6–8

Each style of structured or unstructured noting has advantages and disadvantages but should be consistently used in the most effective and efficient manner. Unstructured notes are seen more commonly with traditional manual documentation, and as the name implies, they are free in form, with appropriate language and chronology. Advantages of this style are that the notes can be written expeditiously while still providing a solid, high-quality, general overview. One disadvantage is the note may be incomplete and inconsistent, which limits communication to other health care professionals, leaving practitioners vulnerable to liability. This type of documentation, whether it be manual or electronic, is usually reserved for phone messages and informal communication between practitioners regarding ongoing patient care issues secondary to the limitations.^1,6,7

To be more complete the majority of manual and electronic documentation follows the systematic approach, allowing for completeness, consistency, and organization. Without a systematic structure, the documentation of the encounter may be time consuming and confusing, especially in regards to the placement of information from different sources. An example of this can be seen when documenting height, weight, and allergies. One clinician may document this information in the subjective findings, and another may place the information within the objective data collection section. The primary determinant for where this information should appear is how the information was collected. Was the information patient reported (subjective) or clinician measured (objective)? This problem may not be as apparent with an electronic documentation since many of the templates allow data to be entered only in certain fields of the encounter note, creating semistructured documentation. This blends different styles for which some fields are more standardized and others are free text. Like unstructured documenting, semistructured documentation may also lack the quality and consistency of the standardized SOAP note. Semistructured noting may be best used when triaging or forming a general impression for referral with no specific action needed by the pharmacist, much like a phone message or reporting of a lab result to the collaborating practitioner.

The more structured SOAP note format is appropriate when follow-up and monitoring are required as well as showing continuity of care provided by the health care practitioner. Both of these documentation styles have been used routinely with written communication and now are slowly being integrated as standards for the majority of EMRs.^1,6,7,10 This is especially true of the SOAP format since it is the primary form for which payers traditionally reimburse.

No matter the format or style, documentation should always be used to demonstrate the impact of your interventions to improve patient care and the overall management of the chronic disease state(s). In addition, the documentation needs to support and allow for reimbursement. All documentation should be complete, complementary, compelling due to supportive evidence, and standardized and systematic to complement the oral communication among providers. Furthermore, documentation should reflect patient agreement with the care plan among multiple providers in terms of medication reconciliation, data collection, continuity of care, and the transitioning of care along the continuum.^{1,6–8,11,12}

Knowing this makes it much more apparent that documentation is more than completing forms or capturing data during a patient encounter. No single ideal format can encompass all patient interviews, yet documentation can still provide evidence of the pharmacist’s interventions in advocacy and patient management. An example SOAP note (Figure 6-1) illustrates a standardized, structured approach to documentation and medication reconciliation, which will be discussed shortly. (Example SOAP Note)

The four distinctive sections of a SOAP note are outlined as follows:^1,6–8

1.   Subjective: symptoms, information, and answers to provider questions that the patient verbally expresses or that are provided by a caregiver. These descriptions provide a clinician with insight into the severity of a patient’s condition, the level of dysfunction, illness progression, and degree of pain.

2.   Objective: measurements that are observed (seen, heard, touched, smelled) by clinician or that can be tested. Examples include vital signs, pulse, temperature, skin color, edema, and diagnostic testing.

3.   Assessment: a prioritized list of assessed conditions. Simply stated, it is what you think are the patient’s issues or problems from your perspective as a pharmacist provider. This may consist of a level of control, differentials, potential confounders to control, pertinent positives or negative signs and symptoms related to the condition, reference to evidence-based medicine (EBM), considerations for pharmacotherapy, and adjunctive lifestyle measures.

4.   Plan: care plan action steps for the patient and health care practitioners. The plan consists of the actions that you initiate or suggest to improve or resolve the issues or problems identified in the assessment. This may include requests for additional laboratory or diagnostic assessments, alterations in pharmacotherapy, lifestyle recommendations, standards of care, special directions, referrals, self-monitoring, emergency contacts, and time for follow-up appointments.

Figure 6-1. Example SOAP Note (written by SL Haines).

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