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2 tools to improve patient assessment and documentation

May 29, 2012

Using ACP’s “Chat, Check and Chart” improves pharmacists’ efficiency and confidence in completing patient assessments and documentation. This finding comes from a recent study that has just been accepted for publication in the International Journal of Clinical Pharmacy.

2 tools to improve patient assessment and documentation

Chat, Check and Chart uses specific questions to improve the efficiency and effectiveness of patient assessment. It also outlines a four-step method to help you quickly yet thoroughly document your interaction.

7 questions for more effective, efficient patient assessment

The 3 Prime Questions (3PQs)

 

1. What are you using this medication for?

2. How were you told to use it?

3. What were you told to expect?

 

Use to efficiently assess the patients’ knowledge and identify information needs. 

You can adapt these for both new and refill prescriptions.

 

The 4 Questions to Evaluate Therapy

 

1. Is the therapy appropriate?

2. Is the therapy effective?

3.Is the therapy safe?

4. Will the patient take the therapy?

Use to help identify, monitor, and prevent medication related problems.

 

 

4 steps to speed up documentation

The eDAP (Patient Data, Pharmacist Assessment, and Care Plan) is intended for the limited space in current pharmacy dispensing software and time available. To document efficiently, enter the following in the record:

  1. Date
  2. Prescription number or title
  3. Briefly describe:
    • Data (subjective and objective)
    • Assessment
    • Plan
  4. Identifier (initials/name)

See an example eDAP.

Resources
Chat, Check and Chart tool card
International Journal of Clinical Pharmacy article

What can ACP help you with next? If there is a practice topic you would like to know more about or a skill you would like to build, we’d love to know. Send your ideas to donotreply@abpharmacy.ca.


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