Pharmacists' documentation in patients' hospital health records: issues and educational implications

Abstract

Abstract Objectives We aimed to identify potential barriers to hospital pharmacists' documentation in patients' hospital health records, and to explore pharmacists' training needs. Our objectives were to identify the methods used by pharmacists to communicate and document patient care issues, to explore pharmacists' attitudes towards documentation of patient care issues in health records, to identify and examine the factors influencing whether or not pharmacists document their care in health records and to make recommendations to inform development of a training programme to educate pharmacists regarding documentation in health records. Methods Methods included a questionnaire and focus groups. The study poulation was 40 clinical pharmacists in a 900-bed London teaching hospital. Key findings Thirty-nine pharmacists completed the questionnaire and 32 attended a focus group. Questionnaire responses indicated that 29 (74%) pharmacists did not write in patient health records; most preferred temporary notes. However, most respondents agreed that documenting their input in the health record was important. Few pharmacists believed that writing in health records would affect the doctor–pharmacist or patient–doctor relationship, or felt that health-record availability or time were barriers. Most knew when, how and which issues to document; however, most wanted more training. Focus-group discussions revealed that pharmacists feared litigation and criticism from doctors when writing in health records. Pharmacists' written communication in health records was also influenced by the perceived significance and appropriateness of clinical issues, pharmacists' acceptance by doctors, and pharmacists' ‘ownership’ of the health record. Conclusions While recognising the importance of documenting relevant issues in health records, pharmacists rarely did so in practice and preferred to use oral communication or temporary adhesive notes instead. Pharmacists need to overcome their fear of criticism and litigation in order to document more appropriately in health records. A trust policy and training may offer pharmacists a sense of protection, enabling more confident documentation in patients' health records.