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Almuqbil M, Alturki H, Al Juffali L, Al-otaibi N, Awaad N, Alkhudair N, Alhammad AM, Alsuwayni B, Alrouwaijeh S, Aljawadi M, Alhossan A, Asdaq SMB. Comparison of medical documentation between pharmacist-led anticoagulation clinics and physician-led anticoagulation clinics: A retrospective study. Saudi Pharm J 2023; 31:101795. [PMID: 37822696 PMCID: PMC10562761 DOI: 10.1016/j.jsps.2023.101795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/16/2023] [Indexed: 10/13/2023] Open
Abstract
Background and objectives High-quality documentation is critical in medical settings for providing safe patient care. This study was done with the objective of assessing the standard of medical records in anticoagulation clinics and investigating the distinctions between notes written by pharmacists and physicians. Methods A retrospective cross-sectional analysis of data from electronic health records (EHRs) was performed on patients who received anticoagulation and were observed at anticoagulation clinics from October to December 2020. Patients were monitored in two anticoagulation clinics, one administered by pharmacists and the other by physicians. The quality of the documentation was assessed using a score, and the note was assigned one of five categories according to its score: very good, good, average, poor, and very poor. The data was analyzed using Stata/SE 13.1. P value<0.05 was considered significant in all analytical tests. Results A total of 331 patients were included. While 160 patients (48.3%) were followed by the physician-led clinic, 171 (51.6%) were by the pharmacist-led clinic. The average age of the patients was 54 ± 15. 60.73% of them were female, and 90.3% of them were Saudi nationals. Warfarin was the most widely used anticoagulant (70%), followed by rivaroxaban (15.7%). Compared to physicians, pharmacists demonstrated very strong documentation (54% vs. 18%). The examination of the variables considered in the study revealed that physicians had significantly less drug-drug interaction documentation (17 vs. 71 times) or drug-food interaction documentation (23 vs. 71 times) than pharmacists. In terms of follow-up frequency, pharmacists were found to adhere to the clinic protocol (150 times) more frequently than physicians (104 times). However, there was no significant difference in therapeutic plan documentation between the two groups. (p = 0.416). Conclusion Pharmacists were more comprehensive in their documentation than physicians in anticoagulation clinics. Unified clinic documentation can ensure consistent documentation within EHRs across all disciplines.
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Affiliation(s)
- Mansour Almuqbil
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Haya Alturki
- Department of pharmacy services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Lobna Al Juffali
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Nourah Al-otaibi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Nada Awaad
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Nora Alkhudair
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah M. Alhammad
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Bashayr Alsuwayni
- Corporate of Pharmacy Services, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Sara Alrouwaijeh
- Corporate of Pharmacy Services, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohammad Aljawadi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alhossan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Kennedy B, Gray C, Ruda L, Semchuk W. Hospital Pharmacists' Documentation of Vancomycin and Aminoglycoside Prescriptive Authority. Can J Hosp Pharm 2021; 74:144-148. [PMID: 33896954 PMCID: PMC8042190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Brandon Kennedy
- , BSc, BSP, is with the Department of Pharmacy Services, Saskatchewan Health Authority - Regina, Regina, Saskatchewan
| | - Carolyn Gray
- , BSP, ACPR, is with the Department of Pharmacy Services, Saskatchewan Health Authority - Regina, Regina, Saskatchewan
| | - Lisa Ruda
- , BSP, ACPR, is with the Department of Pharmacy Services, Saskatchewan Health Authority - Regina, Regina, Saskatchewan
| | - William Semchuk
- , MSc, PharmD, FCSHP, is with the Department of Pharmacy Services, Saskatchewan Health Authority - Regina, Regina, Saskatchewan
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Clinical Pharmacy Activities Documented (ClinPhADoc): Development, Reliability and Acceptability of a Documentation Tool for Community Pharmacists. PHARMACY 2019; 7:pharmacy7040162. [PMID: 31810295 PMCID: PMC6958443 DOI: 10.3390/pharmacy7040162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/21/2019] [Accepted: 11/26/2019] [Indexed: 11/16/2022] Open
Abstract
Documentation of community pharmacists’ clinical activities, such as the identification and management of drug-related problems (DRPs), is recommended. However, documentation is not systematic in Swiss community pharmacies, and relevant information about DRPs, such as consequences or involved partners, is frequently missing. This study aims to evaluate the interrater and test-retest reliability, appropriateness and acceptability of the Clinical Pharmacy Activities Documented (ClinPhADoc) tool. Ten community pharmacists participated in the study. Interrater reliability coefficients were computed using 24 standardized cases. One month later, test-retest reliability was assessed using 10 standardized cases. To assess the appropriateness, pharmacists were asked to document clinical activities in their own practice using ClinPhADoc. Acceptability was assessed by an online satisfaction survey. Kappa coefficients showing a moderate level of agreement (>0.40) were observed for interrater and test-retest reliability. Pharmacists were able to document 131 clinical activities. The good level of acceptability and brief documentation time (fewer than seven minutes) indicate that ClinPhADoc is well-suited to the community pharmacy setting. To optimize the tool, pharmacists proposed developing an electronic version. These results support the reliability and acceptance of the ClinPhADoc tool.
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Zimmer S, Gray C, Roy C, Semchuk WM. Departmental Initiative to Improve Documentation in the Medical Record by Acute Care Pharmacists. Can J Hosp Pharm 2019; 72:151-154. [PMID: 31036977 PMCID: PMC6476581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Stephanie Zimmer
- , BSP, is with the Department of Pharmacy Services, Saskatchewan Health Authority - Regina, Regina, Saskatchewan
| | - Carolyn Gray
- , BSP, ACPR, is with the Department of Pharmacy Services, Saskatchewan Health Authority - Regina, Regina, Saskatchewan
| | - Caitlin Roy
- , BSP, ACPR, is with the Department of Pharmacy Services, Saskatchewan Health Authority - Regina, Regina, Saskatchewan
| | - William M Semchuk
- , MSc, PharmD, FCSHP, is with the Department of Pharmacy Services, Saskatchewan Health Authority - Regina, Regina, Saskatchewan
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