Documenting Patient Interactions: What’s the Role of Pharmacy Technicians?
Complete, up-to-date and accurate patient records enhance patient safety by supporting continuity of care, inter- and intra-professional delivery of care, and optimized decision making.
Pharmacy technicians play an important role by gathering, reviewing, entering and/or updating the information in a patient record. They can also conduct a Best Possible Medication History (BPMH) to support the pharmacist’s clinical assessment and decision-making.
In all patient interactions that pharmacy technicians have, they must ensure that the information provided by the patient corresponds to the information in the patient record. Any discrepancies or updates should be documented in line with the pharmacy’s protocols.
The COMPARED tool below is designed to support pharmacy technicians in consistently collecting and verifying the essential components of patient information by providing examples. While this is one way of doing it, pharmacy technicians are not required to follow the process below as long as the requirements of the Standards of Practice are met and the essential information is collected, documented and used appropriately.
Remember that all documentation should be reliable, retrievable and usable, robust and retained appropriately (review The Four R’s of Documentation article for more information).
COMPARED Tool: What to Document from a Patient Interaction
This guide is not intended to be exhaustive. Pharmacy technicians must exercise professional judgment to determine what additional information may be relevant and when information should be documented. Access a printable version of this graphic.
Crucial information volunteered by the patient during conversations.
Occasionally, patients may voluntarily share health-related information that is critical to their care. Pharmacy technicians should assess the relevance of such information and document it appropriately in accordance with professional guidelines and documentation standards. Examples could include upcoming surgeries, weight loss, a desire to stop smoking, and other health-related goals.
Over-the-counter products.
Document the use of health-related products by the patient that can be purchased without a prescription and may include herbal and natural health products.
Medical conditions.
Accurate records enable the pharmacist to identify and prevent potential drug-condition interactions, which could compromise patient safety. Pharmacy technicians should ensure that all relevant medical conditions are recorded in the patient profile and updated as necessary.
Prescriptions taken elsewhere.
It is important to document all medications a patient is taking, including those obtained from other pharmacies or provided as samples by their prescriber. This ensures a complete and accurate medication profile, allowing the pharmacist to assess for potential drug interactions, duplications, or contraindications.
Allergies.
Allergy information should be collected whenever a new medication is dispensed and at regular intervals thereafter. This information must be accurately documented in the patient’s profile, including the date on which the inquiry was made.
Reactions.
Any reactions to medication are an essential component of information collection. When a patient reports a reaction, pharmacy technicians can follow up by asking, ‘What happens when you take the medication?’ Clearly document that patient’s description of the reaction, as this information can support the pharmacist’s therapeutic assessment of the patient.
For example, the patient may be describing aversions, intolerances, or adverse reactions to medications which may influence medication adherence and assist the pharmacist in their decision-making process.
Education provided to the patient or their agents.
The outcome of any education provided to patients should be clearly documented in the patient profile. This includes a summary of the information shared, any issues or concerns raised during the session, and any follow-up actions required.
In cases where the education involves the use of health-monitoring devices, such as glucometers, the relevant data obtained from the device should also be recorded in the patient’s profile.
Drug indication.
Given that many medications can have multiple approved indications as well as potential off label uses, it is essential to collect and document the specific indication for which a drug is being prescribed. This allows the pharmacist to assess whether the prescribed therapy is appropriate for the intended use.
Although drug indication information can be obtained through different sources (e.g., in writing or verbally from a prescriber), when possible, drug indication information should also be obtained from the patient, to ensure that this is aligned with their understanding and reason for the choice of therapy.
