How to communicate effectively in patients’ medical notes

Writing in patients’ medical notes is essential for communicating and co-ordinating patient care. Pharmacists must be able to document their contributions clearly to the wider multidisciplinary team

This content was published in 2013. We do not recommend that you take any clinical decisions based on this information without first ensuring you have checked the latest guidance.

In short

Pharmacists need to be able to communicate effectively in medical notes to provide accurate, informative and auditable records of the pharmaceutical care they deliver to patients.

Medical note entries should be written professionally, be clearly identifiable and offer practical recommendations regarding patient care.

Medical notes are a collection of information on a patient that includes any relevant history, a statement of his or her current problem, the diagnosis and details of any interventions.1 They are legal documents that should include all the contributions made by the multidisciplinary team involved in a patient’s care throughout an admission to hospital.

Despite regularly reviewing medical notes and reading entries from other healthcare professionals, such as physiotherapists and dietitians, some pharmacists remain reluctant to document their own interventions in the same way. The act of writing correspondence in medical notes still seems to split opinion among clinical pharmacists. Some consider it an integral part of pharmaceutical care; others will rarely, if ever, write in patients’ medical records.

A recent study found that 74% of pharmacists at a large teaching hospital admitted that, for various reasons, they did not write in medical notes.2 One reason, revealed in a focus group, was fear of litigation and criticism from doctors. Most respondents, however, did agree that writing in the medical notes was important.

It is understood that some pharmacists (especially those who are newly qualified) can find documenting their recommendations to other health professionals quite daunting. Nevertheless, pharmacists should take full responsibility for any medicines-related problems their patients may have. Because medical notes are legal documents, if pharmacists contribute to a patient’s care, or make certain recommendations to the multidisciplinary team concerning treatment, then this should be documented accordingly.

Although it is not feasible for pharmacists to document every intervention they make, there are occasions when a record should be written (see Box 1).

Box 1: When pharmacists should write in medical notes

  • The following pharmaceutical contributions should be documented in medical notes by the pharmacist: 
  • Clarification of a medication history 
  • Details of patient education provided, eg, counselling on anticoagulation or inhaler technique, or how to use a compliance aid
  • Therapeutic drug monitoring information, eg, requesting a test, rationale and any advice in response to results 
  • Medicines-related issues, eg, contraindications to prescribed medicines, serious adverse drug reactions, clinically significant drug interactions
  • Medicines-related issues that warrant close monitoring, eg, declining renal function 
  • Answers to queries raised by the medical team 
  • Information or advice given to patients or clinicians, eg, regarding medicines use during pregnancy or breastfeeding, or for patients with renal or liver impairment 
  • To alert clinicians that a medicines review is required, eg, in response to a change in clinical condition, to review the duration of an antibiotic or corticosteroid order 
  • Information regarding certain patient groups, eg, patients on opiate substitution therapy should have their usual dose and community drugs team documented 
  • Details of medicines started, stopped or changed by an independent pharmacist prescriber, and the rationale behind the decision

Auditable records

Pharmacists often communicate recommendations to prescribers using temporary sticky notes on drug charts or through writing in doctors’ job books. Although these methods of communication may ensure a recommendation is acted on, they are not auditable legal documents. If any legal or clinical queries were to arise after the event then it would be difficult to recount exactly what had been recommended and when. These methods are also unreliable: the loss of a temporary adhesive note has been reported to have contributed to the death of a patient.3

Many hospitals now have electronic prescribing systems that allow pharmacists to make notes on care planning to communicate with clinicians. Such systems are useful but they should not replace pharmacists writing in the medical notes, which are accessible for all healthcare professionals.

Furthermore, writing in medical notes should not replace a direct conversation with the appropriate healthcare professional. If someone suitable is not available to speak to, then documenting information in the medical notes may be the only viable means of communication. However, depending on how urgently the intervention needs to be addressed, further attempts to speak to the clinician may be required. For example, if a patient is not correctly prescribed his or her antiepileptic medicines on admission then an entry should be made in the medical notes and a doctor must be contacted promptly to avoid any delay in the patient receiving a dose. For the addition of a less urgent medi cine (eg, a multivitam in) to a patient’s drug chart, an entry in the notes may suffice.

Professionally written

There is a standard level of professionalism that needs to be upheld when writing in medical notes and these written communication skills are essential for all pharmacists.

Pharmacists should remember always to indicate clearly that the entry is from pharmacy, and to sign and print their names at the end of an entry. Entries should be concise, accurate and written in a polite manner that is non-judgemental.

Pharmacists should offer recommendations, not orders, that will result in the appropriate action being taken by the medical team. Figures 1 and 2 provide examples of how an entry into medical notes should, and should not, be written.

The Royal College of Physicians has published a generic medical recordkeeping toolkit4 in an attempt to improve the standard of medical records. Some tips to help pharmacists for mat their entries have been extracted from the toolkit and are set out in Box 2.

Box 2: Top tips

As recommended by the Royal College of Physicians, here are some tips to remember when writing in medical notes: 

  • Confirm the patient’s details are correct on every document written on
  • Record the date and time (using the 24-hour clock) 
  • Clearly indicate that the note is from pharmacy and include a brief description of the entry 
  • Use the generic names of medicines (brands may be appropriate in some local policies) 
  • Write in black pen or green gel ink (or as agreed in local policy) 
  • Avoid using abbreviations. If necessary, use abbreviations that are unambiguous and well known 
  • Write clearly in a legible manner and use block capitals if needed 
  • Write objectively 
  • Be concise and accurate 
  • Do not comment about unrelated issues or on matters beyond your expertise 
  • Document discussions with other healthcare professionals and include full names, job titles and the agreed course of action 
  • Sign and print your full name, profession and contact details

Build confidence

Some pharmacists may worry that an entry they make in medical notes could adversely affect working relationships with doctors and other healthcare professionals if it is of a contentious nature.

It is good practice to discuss any contentious issues with all staff involved, to gather the information needed to make a well founded entry. Junior phar macists are advised to discuss situations with a senior colleague if they are concerned about writing an entry.

Employers should have internal policies that offer training to pharmacists, and other staff , on how to write in medical notes. This should help pharmacists build confidence in the activity and help them make entries that are appropriate and valuable to the pharmaceutical care of their patients.

References

1 General Medical Council. Good medical practice. March 2009. www.gmc-uk.org/static/documents/ content/GMP_0910.pdf (accessed 28th January 2013).

2 Pullinger W, Dean-Franklin B. Pharmacists’ documentation in patients’ hospital health records: issues and educational implications.International Journal of Pharmacy Practice 2010;18:108–15.

3 Francis S. There’s more to interprofessional communication than sticky notes. Pharmaceutical Journal 2001;267:460.

4 Royal College of Physicians. A clinician’s guide to record standards. October 2008. www.rcplondon.ac.uk/ sites/default/files/documents/clinicians-guide-part-2- standards.pdf (accessed 28th January 2013).

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Citation
Clinical Pharmacist, CP, 2013;()::DOI:10.1211/PJ.2021.1.65714