During recent pharmacy inspections, ACP’s pharmacy practice consultants have observed an increased use of computer-generated templates for clinical care documentation. While templates can serve as a helpful reminder to include key information, and can help make documentation more efficient, they are not a replacement for the comprehensive, patient-specific, and accurate assessments pharmacists are expected to conduct to satisfy the Standards of Practice for Pharmacists and Pharmacy Technicians (SPPPT).
Some templates can automatically populate standardized information based on health conditions entered into a patient’s record. As an example, for any patient with obesity, a template might generate identical care plan documentation with the same goals of therapy and recommendations as seen below:
- Goals of therapy
- Stabilize and prevent further weight gain
- Prevent weight regain
- Prevent and treat obesity-related comorbidities and complications
BMI: 32
- Monitoring plan
- Start 30 minutes or more of continuous or intermittent physical activity at least five days each week
- Implement nutritional interventions so they are culturally acceptable, affordable, and meet the patient’s individual values and goals
This documentation could apply to any patient with obesity or cardiovascular-related conditions, and there is no patient-specific data (other than BMI) to tailor the treatment plan.
Patient care starts with establishing a professional relationship with your patient and collecting specific information to identify their individual health needs and expectations. Goals of therapy and monitoring plans are only useful if they are tailored to what is appropriate for each specific patient.
General information also does not help to establish a baseline for future comparison. When following up with a patient about a prescribed medication or a care plan, regulated members need to record sufficient details to ensure continuity of care. Monitoring progress means you need to record specific data to establish a baseline that enables comparison by you or another pharmacist at the next patient encounter. Another pharmacist should be able to review your patient-specific assessment and easily understand and implement your documented follow-up plan.
An excess of generalized information and recommendations effectively creates an inaccurate patient record that is detrimental to monitoring and supporting continued care. Your documentation must be tailored to indicate the exact care you did provide.
Providing care that is person centred is necessary to achieving the best outcomes for patients. Remember that while templates are a tool that may support care, they must be used in a manner that is patient specific and that accommodates compliance with all relevant standards. See the Chat Check Chart tool Plotting the “Chart” for more information on incorporating templates into your practice.
