Pharmacy professionals are expected to document the patient care they provide to enable collaboration and continuity of care. This includes documenting interactions, decisions and the supporting rationale as well as their actions, to which they are accountable, on the patient’s record.
Documentation must be done in a timely and effective fashion, using recognized formats that are easily understood by the patient’s circle of care. The standards of practice, supplemental standard of practice and Documentation Guideline outline the responsibilities of pharmacy professionals, and specific documentation requirements are provided in other College Policies when necessary.
The supplemental standards supporting the College’s mandatory Assurance and Improvement in Medication Safety (AIMS) Program require documentation of medication incidents, continuous quality improvement (CQI) plans and outcomes of staff communications.
This professional obligation and skill is evaluated during a pharmacist and pharmacy technician practice assessment as part of the College’s Quality Assurance Program.