Tip of the Week: Documenting Patient Interventions Is Essential

Most everyone has heard the age-old question of whether a felled tree makes a sound if there was no one there to hear it. Likewise, many of us have heard the saying, “If you didn’t document it, it didn’t happen.” Yet, in spite of this, it seems as though pharmacy personnel still fall well short of documenting their interventions.

Rivera et al evaluated types of medication-related problems (MRPs), interventions, and documentation among patients receiving medication therapy management (MTM) in person versus over the telephone.1 They conducted a retrospective analysis on all completed comprehensive medication reviews over the span of 7 years in 14 community pharmacies.

The most common MRPs included Beers criteria medications (mostly antidepressants, protein pump inhibitors, gabapentin, and opioids), medication omission, drug-condition interaction, duplicate therapy, medication nonadherence, drug-drug interactions, untreated conditions, dose that were too low, and doses that were too high. MRPs were also equally prevalent among face-to-face versus phone interventions.

However, the presence of documentation in the “assessment” section of the comprehensive medication review (CMR) was higher when MTM was conducted via phone (42%) compared to face-to-face (28%). Similar results were seen in the “plan” section of the CMR (meaning a plan was documented). The research corroborated previous studies which suggest that uptake of reviews and documentation are more common with a telephonic option when treating patients with asthma.

Rivera et al concluded that with just over one-third of CMR entries indicating assessment and care plan completion, there are a proportion of patients who likely remain under-evaluated. They also indicated that pharmacists are likely missing out on opportunities to engage in thoughtful, evidence-based deprescribing attempts with their patients.

The lack of documentation could become even more problematic as pharmacists attempt to garner payment for providing services. If further scrutinized, the issue represents a potentially momentous lost opportunity to demonstrate that pharmacists provide comprehensive and more holistic care, rather than mere transactional care. Higher rates of phone documentation might be an indication of ease to complete these types of activities versus face-to-face, but this requires further study.

The study’s authors conclude that it is critical for MTM providers to close the communication loop between the prescriber and the patient and to ensure timely resolution of MRPs. With documentation, the authors said the MTM is likely to significantly improve medication use processes.

Pharmacists are doing some great things and advancing the state of practice; however, they might look to themselves when others are asking for proof that they are doing so. Pharmacists are taking advantage of new opportunities, but there remain many other opportunities yet to be seized.

Additional information about Operations Management can be found in Pharmacy Management: Essentials for All Practice Settings, 5e.

Shane P. Desselle, RPh, PhD, FAPhA, is a professor of social and behavioral pharmacy at the Touro University California College of Pharmacy.

REFERENCE

Rivera J, Shcherbakova N, Vala C, Capoccia K. Community pharmacists’ interventiosn and documentation during medication therapy management encounters delivered face-to-face versus via telephone: The devil is in the details. Res Social Adm Pharm. 2020;16(10):1447-1451.