Lacy C F, Saya F G, Shane R R
Department of Pharmacy Services, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
Am J Health Syst Pharm. 1996 Sep 15;53(18):2171-5. doi: 10.1093/ajhp/53.18.2171.
Training pharmacists to appropriately document patient-specific problems and recommendations in patients' medical records and subsequent monitoring of pharmacist-written documentation are described. The medical staff of a tertiary care teaching hospital recommended that pharmacists be allowed to write in the permanent portion of patients' medical records. A six-month pilot program was approved to train pharmacists in writing chart notes. Notes would be assessed according to the following criteria: necessity (i.e., a chart note was the appropriate means of communication), clarity, legibility, completeness, correct format, and lack of judgmental language. Initial training was by physicians from the pharmacy and therapeutics committee, with more extensive training by a committee composed of clinical and administrative pharmacists. After training ended, each pharmacist's first few notes were reviewed by a member of the pharmacy committee. The quality of pharmacist-written notes is reviewed quarterly. The first quarterly evaluation and another review 1 1/2 years later showed that all pharmacist notes met all of the established criteria. A multidisciplinary approach was effective in training pharmacists to document interventions appropriately in patients' permanent records. Ongoing monitoring ensures the continuing quality of such documentation.
本文描述了培训药剂师在患者病历中恰当记录患者特定问题及建议，并对药剂师书写的文档进行后续监测的过程。一家三级护理教学医院的医务人员建议允许药剂师在患者病历的永久部分进行书写。一项为期六个月的试点项目获批，用于培训药剂师书写病历记录。记录将根据以下标准进行评估：必要性（即病历记录是合适的沟通方式）、清晰度、易读性、完整性、正确格式以及无评判性语言。初始培训由药学与治疗学委员会的医生进行，更广泛的培训则由临床和行政药剂师组成的委员会开展。培训结束后，药房委员会的一名成员会审查每位药剂师最初书写的几份记录。药剂师书写记录的质量每季度进行审查。首次季度评估以及1年半后的另一次审查表明，所有药剂师的记录均符合所有既定标准。多学科方法在培训药剂师在患者永久记录中恰当记录干预措施方面是有效的。持续监测可确保此类记录的质量持续良好。
