Académique Documents
Professionnel Documents
Culture Documents
1. Why record interventions? All sectors should establish robust mecha- 3. What to record
There are four main reasons why pharmacists nisms for sharing information that could be The level of detail necessary for recording
should want to record their interventions: used by other pharmacists to improve the interventions will vary depending on each
overall standard of pharmaceutical care. situation. Pharmacists should aim to keep
To help ensure patient safety and improve the records concise by recording only what
the quality and continuity of patient care 2. When to record interventions is important and excluding any extraneous
To provide evidence to demonstrate the Pharmacists are not required to record every information.
additional value of pharmacist professional intervention they make or to record all the It may be necessary to record some or all
input into a procedure such as dispensing, advice that they give. However, the following of the following details:
over-the-counter sales, etc, and improve- should be considered for recording:
ment in patient care through their clinical Identification of patient or other person
input to prescribing Interventions that are of clinical signifi- involved, where possible, or a brief de-
To have an accurate record available for cance (ie, could be regarded as having a scription of the patient/person
scrutiny where decisions could be chal- direct impact on patient care) Name and address of patient/person, if
lenged, eg, intervention on prescribing Interventions that provide learning oppor- available
quality or accuracy tunities to improve overall standards of NHS number if available
For monitoring incidents or near misses in care Name of regular GP and/or practice or
relation to the prescribing, dispensing or Interventions that could potentially be hospital consultant
administration of medicines as part queried or refuted (so that a record is Medical conditions
of an organisations clinical governance available for future reference) Date of intervention
framework If the patient or patient representative Time of intervention
queried or disagreed with the intervention Name of person who made the interven-
Although this guidance focuses on com- If the intervention affects or impacts on tion or gave the advice
munity pharmacy systems, the recording of another member of the health care team Patient condition or concern
interventions applies wherever a pharmacist referral or refusal of disclosure Summary of intervention including out-
practises. The entry should serve as a record If the intervention relates to an extended comes or proposed courses of action
of the critical thinking and judgement the service that the pharmacist is being paid Names and roles of other people involved
pharmacist has used in assessing the situation for and is contracted to provide in the intervention or contacted
and then go on to describe events and dis- It may also be necessary to record all in- Sources of information used
cussions he or she has had with patients, pa- terventions over fixed periods of time on a
tient representatives or other health and social regular basis (point prevalence studies) to A pharmacist may not always have at hand
care professionals to effect that decision. establish workload trends, or patterns of all the information needed to make a detailed
Recording interventions demonstrates the medication-related problems record. Information recorded should be of as-
degree of responsibility and accountability the sistance should there be a subsequent enquiry
pharmacist has taken for his or her professional Records of interventions should be made regarding the nature of the intervention.
activities and is a key component in demon- as soon as possible after the event has oc- All records made should be well organised
strating how professional judgement is applied. curred. This enables the recording of details and legible, only using clear and established
Records should not be limited to pre- to be more accurate. abbreviations that are common to all health
scription interventions but should include Appendix 1 contains examples of inter- care professionals. These records should not
any situation where a pharmacist makes a sig- ventions that could be recorded in both contain any unfounded opinions or conclu-
nificant contribution to patient care. primary and secondary care. sions and where conclusions are drawn these