Development of a Documentation Rubric and Assessment of Pharmacists' Competency for Documentation in the Patient Health Record.

ABSTRACT:

Background

Documentation of information in the health record by pharmacists is vital to patient care. Failure to document, or failure to document appropriately, may have negative effects on patients.

Objectives

The primary objective was to determine pharmacists' competency in 18 elements of chart note documentation at 2 tertiary care centres and 1 rehabilitation centre. The secondary objectives were to quantify the number of episodes of documentation by pharmacists, to characterize the clinical activities associated with this documentation, and to determine whether there were differences in level of competency according to years of hospital experience, additional clinical training, and note type.

Methods

This study used prospective audit methodology. Notes documented

SUBMITTER: Baranski B 

PROVIDER: S-EPMC5737184 | biostudies-literature | 2017 Nov-Dec

REPOSITORIES: biostudies-literature