J Am Pharm Assoc (2003). 2021 Jul-Aug;61(4S):S161-S166. doi: 10.1016/j.japh.2020.12.023. Epub 2021 Jan 24.
Pharmacists in community-based settings document patient care using the Pharmacist eCare Plan (PeCP).
To conduct a pilot evaluation of the PeCP use and documentation of Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT) codes within select community-based pharmacies.
Moose Pharmacy operates 7 locations in rural North Carolina that are part of the Community Pharmacy Enhanced Services Network (CPESN). The Moose Pharmacy Medication Adherence Program (MooseMAP) targets patients with a chronic condition who would benefit from medication synchronization, adherence packaging, and monthly calls.
CPESN pharmacies use the PeCP to track a patient's concerns, goals, interventions, and medication-related information. The PeCP standard requires pharmacies to detail a patient's current medication regimen and health concerns as well as the pharmacy's interventions and patient's health over time.
Data were included if the patient was enrolled in MooseMAP and had a free-text note in the eCare Plan. Data were excluded if the medication-related problem (MRP) or intervention was a general health problem without a valid SNOMED CT code. Data were categorized into MRPs, medication interventions, education, and referrals. The International SNOMED CT browser and pharmacy health information technology (PHIT) value sets were searched; data sets without existing codes were submitted to the appropriate oversight authorities for future inclusion. Data were analyzed using descriptive statistics.
Emerging codes were identified that resulted in 91 recommendations to PHIT for development of new SNOMED CT codes and 113 recommendations to PHIT for inclusion in the PHIT value sets. In total, 66% of MRPs did not have a valid SNOMED CT code, and 78% of MRPs were not included in a PHIT value set. The most prevalent gap in MRP or intervention documentation related to medication use issues.
Incorporating emerging codes into documentation systems should enable the profession to better communicate value to health care stakeholders.
社区环境下的药师使用电子护理计划（eCare Plan）记录患者护理情况。
在选定的社区药房中，对电子护理计划的使用情况以及系统命名法医学术语（SNOMED CT）编码的文档记录进行试点评估。
Moose 药房在北卡罗来纳州的 7 个农村地点运营，是社区药房增强服务网络（CPESN）的一部分。Moose 药房药物依从性计划（MooseMAP）针对患有慢性病且受益于药物同步、依从性包装和每月电话咨询的患者。
CPESN 药房使用电子护理计划来跟踪患者的关注点、目标、干预措施和与药物相关的信息。电子护理计划的标准要求药房详细记录患者当前的药物治疗方案和健康问题，以及药房的干预措施和患者的健康状况随时间的变化。
如果患者参加了 MooseMAP 并在电子护理计划中有一个自由文本记录，则包含数据。如果药物相关问题（MRP）或干预措施是一个没有有效 SNOMED CT 代码的一般健康问题，则排除数据。数据被分为 MRP、药物干预、教育和转诊。搜索了国际 SNOMED CT 浏览器和药房健康信息技术（PHIT）值集；对于没有现有代码的数据，提交给适当的监督机构，以供将来纳入。使用描述性统计对数据进行分析。
确定了新出现的代码，为 PHIT 开发新的 SNOMED CT 代码提出了 91 项建议，并为 PHIT 纳入 PHIT 值集提出了 113 项建议。总的来说，66%的 MRP 没有有效的 SNOMED CT 代码，78%的 MRP 没有纳入 PHIT 值集。在 MRP 或干预措施文档记录方面，最常见的差距与药物使用问题有关。
将新兴代码纳入文档系统应该使该专业能够更好地向医疗保健利益相关者传达价值。
