Objective. The Alberta Cancer Board (ACB) Pharmacy recognizing the significance and merits of intervention documentation examined the reporting methods at the ACB’s two major tertiary cancer treatment centres, the Cross Cancer Institute (CCI) and the Tom Baker Cancer Centre (TBCC). The goal of the project was to identify interventions and actions performed by pharmacists and the resulting outcomes. This information would then be forwarded to the pharmacy computer team to implement electronic documentation of clinical interventions utilizing the pharmacy software program (RxTFC).
Data Sources. The student collected information through focus groups, literature reviews, shadowing and interviewing pharmacists, manual/paper documentation review and checking the ‘notes’ section of the computer software program (RxTFC).
Study Selection. Published literature on intervention documentation was researched and those relevant to clinical documentation in ambulatory care settings were selected.
Data Extraction. There was an extensive data collection process, a student researcher was able to define, identify and develop the types of interventions and actions that ACB pharmacists perform daily and the outcomes of the provision of these clinical services. Mosby’s definitions for intervention, action and outcome were adopted in order to aid when sorting and classifying data collected.
Data Synthesis. The types of documentation and a list of interventions and actions are summarized in tables. The results indicate that manual forms that are currently in ACB pharmacies are not being used to their full capacity and/or are not being used as they were originally intended. Possible reasons are a lack of self-reporting, differing reporting styles among pharmacists, a lack of time and/or inconvenient manual documentation systems currently in place. Also, pharmacists differ in their perceptions on what constitutes an intervention. Advantages and disadvantages of both manual and electronic reporting practices are outlined.
Conclusions. Clinical intervention documentation is an important tool for pharmacists to ensure that patients are provided with the best pharmaceutical care available in oncology settings. J Oncol Pharm Practice (2001) 7, 35-46
Mutnick AH, Sterba KJ, Szymusiak-Mutnick BA.The integration of quality assessment and a patient-specific intervention/outcomes project. Pharm Pract Manage Q. 1988;17:25-36.
2.
Allen M, Farris K.A practical approach to documenting pharmacists’ interventions. Can Pharm J. 2000;132: 36-42.
3.
Davies N, Spaven JR, Chambers CR.Comprehensive clinical pharmacy documentation in an outpatient cancer facility. Can J Hosp Pharm. 1992;45:107-112.
4.
Pharmaceutical Care Advisory Committee of CSHP. An information paper on documentation of pharmaceutical care in the health care record. Off Publ, Can Soc Hosp Pharm. 1996;3-14.
5.
BDM RxTFC (Pharmacy for the Twenty First Century). BDM Information Systems 2001. 406, 15 Innovation Boulevard. Saskatoon, Saskatchewan. S7N 2X8. (306) 933 3000.
6.
Mosby’s Medical, Nursing, and Allied Health Dictionary. St. Louis Missouri, 1998;5:858-858, 24-24, 1174-1174.
7.
ASHP statement on the pharmacist’s clinical role in organized health-care settings. Am J Hosp Pharm. 1988;45:890-891.
8.
Louie N, Robertson N.Barriers to pharmaceutical care in the managed care setting. Am J Hosp Pharm. 1993;50:1614-1617.
9.
Lacy CF, Saya FG, Shane RR.Quality of pharmacists’ documentation in patients’ medical records. Am J Hosp Pharm. 1996;53:2171-2175.
10.
Shane R, Saltiel E, White JY, Flascha ST.Using documentation of pharmacists clinical activity. Am J Hosp Pharm. 1991;48:2647-2648.
11.
Simonian RI.Computerized documentation of clinical pharmacist interventions. Top Hosp Pharm Manage. 1989;9:62-67.
