Communication & Documentation

for an Ambulatory Practice

Seena L. Haines, Timothy R. Brown CHAPTER

Chapter Outline Chapter Objectives

1. Introduction 1. Identify the relevance for
pharmacists’ documentation of
2. Documentation Styles
clinical services
3. Documentation Elements
2. Compare and contrast manual
4. Communication Techniques and electronic documentation
systems
5. Medical Liability and Auditing
3. Review the common documen-
6. Chapter Summary
tation styles and communica-
7. References tion techniques used in clinical
practice
8. Additional Selected References
4. Recognize the appropriate
9. Web Resources
levels for billing based on an
example of documentation
5. Discuss continuous quality
assurance and other safety
measures when implementing
and maintaining documentation

Introduction
Regardless of your practice environment, you will need to use electronic and manual
methods of documentation to communicate, exchange information, and educate
patients, caregivers, and other health care professionals. Like other health care pro-
viders, you will primarily use the patient medical record (PMR) for documentation
of patient care. Through efficient and comprehensive documentation you can (1)
meet professional standards and legal requirements, (2) communicate with other

1
2 Chapter 6

health care professionals, (3) establish accountability for medication-related aspects

of direct patient care, (4) strengthen transition and continuity of care, (5) create
your record of critical thinking and judgment, (6) provide evidence of your value
and workload allocation, (7) justify reimbursement for cognitive services, and (8)
provide needed data for tracking of patient health outcomes.1
Currently, industry-driven advances in technology are having a profound effect
on how pharmacists document and are also creating new challenges. With the pas-
sage by Congress of the stimulus package (the American Recovery and Reinvest-
ment Act, or ARRA), expansion of health information technology (HITCH) is now
mandated by the U.S. government. ARRA budgeted approximately $150 billion
for health care reform and close to $34 billion for health care provider adoption of
HITCH and a nationwide health record system by 2014.2 The most critical element
to the e-health system is the electronic medical record (EMR) and the electronic
health record (EHR). An EMR is a portal that shares relevant patient information
among health care professionals. Likewise, it can perform as a patient scheduler and
an intraoffice messaging system as well as assist with laboratory communications, e-
prescribing, and billing processing. An EHR is an individual patient medical record
digitized from many locations or sources, including the patient and family mem-
bers. It can interface with evidenced-based treatment algorithms and protocols,
outcomes reporting, and quality assurance and is synonymous with what is also
called the patient medical record (PMR). An electronic personal health record (ePHR)
can be created by patients, physicians, pharmacies, health systems, and other sources,
but originates from a patient.2
An EMR and EHR can enhance provider communication in all health care set-
tings. EMRs are primarily focused on physician and hospital-based practice, but
there is potential for benefit in pharmacy practice with wider implementation. EMR
adoption is predicted to bring the following patient and health care provider ben-
efits: lower costs, quality care, improved reimbursement, enhanced productivity,
efficiency, effectiveness, and communication.2
While the EMR has promise of advancing patient care and can be a resource to
capture patient encounters, it is not without its challenges. This is especially true in
the primary care setting due to the sheer number and small size of ambulatory orga-
nizations. Pharmacists practicing in the ambulatory patient care arena have histori-
cally used a modified SOAP (subjective, objective, assessment, plan) note format to
document patient encounters, with sections expanded or omitted based on rel-
evance to the practice and scope or service. It has been physician, and not pharma-
cist, work flow that has driven creation, adoption, and integration of most outpa-
tient EMR and PMR applications. Consequently, it has been difficult to alter or
adapt a physician-driven EMR to fit the work-flow dynamics of a pharmacist-pro-
vided visit in the ambulatory setting. For example, most templates that fit individual
disease states have predetermined signs and symptoms that are consistent with a
pharmacist’s visit, such as documentation of hypo- or hyperglycemic symptoms for
diabetes; however, pharmacists do not perform eye exams routinely, thus docu-
menting a normal eye exam would be inappropriate in the template. This is where
the EMR can be tricky for the pharmacist because both are normally included in a
diabetes visit template. This is important since it relates to payment for clinical
Communication and Documentation for an Ambulatory Practice 3

services. Although pharmacists do not perform detailed physical exams, we do ad-

dress complexity, such as multiple disease states, some aspects of review of systems
(ROSs) and physical exams (PEs), monitoring, follow-up, and capturing of outcomes.
Documentation on templates is designed to emphasize and ensure that the appro-
priate information is in place for billing using the correct evaluation and manage-
ment service codes. Using a template that has incomplete sections or that can be
billed inappropriately (physician services versus a midlevel provider services) could
result in devastating financial and legal consequences for your organization. De-
pending on your EMR, investigate whether it has the ability to code and recognize
language used in your template to populate other fields in the PMR to ensure cor-
rect billing for your services, to collect data related to your services, and to gener-
ate a list of patients for whom you have provided care. If not, you should consider a
separate clinical pharmacy documentation system to capture your needed docu-
mentation. Optimally it should integrate in some form or manner with your
organization’s EMR.

CASE
In Dr. Busybee’s office they have already converted from a paper PMR to
an EMR. Now that all the logistics of seeing patients in the office are
resolved, you must determine how you want to document your interaction
with each patient. After a review of the current EMR you noticed that none
of the disease state templates address anticoagulation management;
however, the good news is the diabetes management template used by the
physicians could be used for your visits as well. Knowing that you have no
built-in system to document care given for patients using an anticoagulant,
you approach the office manager about changing the EMR. The office
manager promptly tells you this is outside their expertise and that they
want nothing to do with changing the EMR setup. Dr. Busybee really does
not understand why you cannot just type your encounter note into the
EMR. You attempt to explain the volume of patients and the time
commitment for that type of documentation. His response is “We use the
EMR in this office — make it work so I can start referring patients to you
as soon as possible.”

Because EMRs generally are not created with clinical pharmacy practice in mind,
you may have already concluded it will be important for you to collaborate with
your institutional information technology (IT) personnel as well as pharmacy man-
agement system (PMS) vendors as needed to develop the necessary technical inte-
gration solutions that incorporate your work flow and corresponding documenta-
tion requirements.2 This seems like a straightforward solution; however, many IT
personnel have no experience with pharmacists seeing patients in an ambulatory
setting or with the details of how we document, so they may be unwilling or lack
4 Chapter 6

sufficient knowledge to build a special area for a pharmacy visit within the adopted
EMR. This can be further complicated by the fact that not all EMRs are created
equally, and the adopted EMR may require a major system overhaul or significant
financial outlay to accommodate your clinical services. You should be prepared to
educate IT personnel on how you document your patient encounters, such as the
need for a universal template for all pharmacotherapy-based visits and specific dis-
ease-state templates (e.g., diabetes or anticoagulation). An existing physician tem-
plate may be used with minor or no alterations.
How do you know which type of templates work for you within an EMR? Just
like other challenges in the pharmacy world you will need to research and investi-
gate the functionality of the proposed or current EMR at your site. Visit the EMR
vendor web page and familiarize yourself with the advantages and disadvantages of
the application and whether the system can address the needs of midlevel providers
such as the clinical pharmacist. Reviewing articles and attending lecture series as
well as professional meetings may help, but usually it requires your review of your
particular system to solidify its application to your services. One resource is the
American Medical Association’s online bookstore.3 Currently, there are several books
available that discuss types of EMRs, as well as incorporation and maintenance of
the systems. Granted, pharmacists rarely have a vote in the decision regarding which
system is purchased for outpatient services, but such EMR resources can educate
you on which systems allow specialization and customization and which are more
restrictive in adapting to midlevel provider patient care services.
Once you understand your EMR’s flexibility and how your services will inte-
grate into the EMR system, you can begin to create or adapt your current manual
patient care notes to an electronic template format. The majority of EMRs do use a
SOAP-based format, but it may appear unrecognizable because many systems fol-
low a point-and-click process rather than use free text for documenting. No matter
which format, you will have to integrate your documentation within the systematic
approach designed by the EMR’s manufacturer. It is imperative that your documen-
tation work flow be developed with your input and feedback to ensure the docu-
mentation process is efficient, easy to use, synergistic with the flow of the patient
visit, and captures all the needed information. If the process is not scrutinized thor-
oughly, you may find yourself inefficiently jumping around the screen or having to
type a large amount within your template; this leads to less time spent seeing pa-
tients and ultimately decreasing productivity and reducing reimbursement, which
affects the viability of your practice.
One solution is to critically assess work flow with IT assistance to create an
electronic template that is geared toward practice functions (pre-visit information
gathering, visit documentation, orders you are able to execute, and billing) as well
as the type of patient care visits you encountered. One example is an anticoagula-
tion visit in which the international normalized ratio (INR) is obtained by the nurs-
ing staff while they are doing vitals and preparing the patient room for the office
visit. You may then enter the room to complete your visit with information already
entered into the electronic note. Alternatively, you, a resident, or your advanced
practice clerkship student could be responsible for performing vitals, point-of-care
testing, and the interview. The work flow and thus the note would be different. The
Communication and Documentation for an Ambulatory Practice 5

key is to create your template around the structure and flow of your patient visit.
No matter which work flow and template is incorporated, your note should always
contain the following elements:
• time of arrival and departure
• chief complaint
• history of present illness
• past medical history
• allergies
• social history
• family history
• appropriate referrals
• labs
• medication reconciliation
• assessment and plan
(Example Documentation Elements for EMR/PMR)

CASE
Over the past 3 months you have slowly integrated into Dr. Busybee’s
practice, and your office hours have gained momentum to where you are
seeing approximately 20 patients per week spread out over 2 days. Dr.
Busybee calls you into his office to discuss how the first quarter has gone
and wants to know if you are “keeping track” of your impact. After some
thought, you admit the last 3 months have been busy and just keeping up
with the clinical aspect of your job has taken a great deal of time. Dr.
Busybee reminds you of your business plan proposal and would like you to
create metrics and outcome measures to ensure you are meeting your
goals. In the meantime he has been approached by a local pharmacy
school and asked if his office would allow pharmacy students to complete
an Ambulatory Care rotation. They are offering compensation for each
student, and he believes this is a perfect fit since they have you in their
practice. This allows for additional revenue to the office and helps pay
your salary. You agree to act as a preceptor with the first student starting
in 2 months. The first thought you have is: How will I integrate these
students into my clinical practice site, how best can I utilize students to
help me accomplish my work, and what hurdles do I face with
documentation if I allow students to see my patients?

Once you have your work flow outlined and templates designed, the next step is
6 Chapter 6

to ensure the security of your system. The overall security will be created and imple-
mented by the IT department; however if the setting is an experiential training site,
you will need to create security measures that limit the access of your pharmacy
students. For a thorough experience, students will need access to the EMR with their
own log-on information; however, their integration must be limited so they cannot
“complete” an encounter note without your preceptor’s electronic signature.
Another consideration is integrating pharmacy residents that are completing
training at your institution into your documentation process. As pharmacy resi-
dents are licensed pharmacists and generally should receive greater autonomy, you
may wish to create an electronic preceptor section within the encounter note that
allows the preceptor to add addenda and cosign the resident’s completed note. This
allows supervision by the preceptor, a level of autonomy for residents, and billing
for the visit, since technically the precepting pharmacist is the collaborating midlevel
provider, not the pharmacy resident.
Despite the many challenges, transitioning to an EMR and computerized pro-
vider order entry (CPOE) is the future and a requirement under new Medicare Part
D regulations that were effective in 2009. Technological advancement certainly
facilitates generation and transfer of documentation and holds much promise to
improve patient safety, although many concerns still exist, such as access to data
(storage) and patient confidentiality. The American Society of Health-System Phar-
macists (ASHP) has an investment to “increase the extent to which health systems
apply technology effectively to improve the safety of medication use.” ASHP has
identified several targets to aid in goal achievement, including enhanced use of
CPOE and EMRs, along with enhancement of information access and communica-
tion across the health care continuum. Since 2005, pharmacists in 19% of health
systems transfer information to promote seamless care of patients with complex
medication regimens. ASHP strives to increase integration of technology as the
new pharmacy practice model is defined and adopted by practice sites.2,4

Documentation Styles
Whether the information is typed or written into a PMR, the documentation of a
clinical interview should provide (1) what happened, (2) to whom, (3) who made it
happen or the cause of the event, (4) occurrence, (5) rationale for why it occurred,
and (6) outcome of action.1,5-9 A survey among community-based pharmacists iden-
tified the following primary characteristics of ideal documentation practices: com-
prehensiveness, affordable cost, time efficiency, ease of use, and ability to generate
patient reports.5 Additionally, with our improved understanding of the perils asso-
ciated with patient transitions of care, communication and coordination of care
documentation should be added to this list. Several documentation styles can and
have been adapted to record pharmacist encounters, including unstructured notes,
semistructured notes, and systematic records, all possible in written documentation
and growing in popularity within EMR formats. No matter the format and media,
documentation should be
• clear,
Communication and Documentation for an Ambulatory Practice 7

• concise,
• legible,
• nonjudgmental,
• patient focused,
• standardized, and
• confidential. 1,6-8
The most common format used in the medical system is systematic documenta-
tion, which includes SOAP, TITRS (title, introduction, text, recommendation, sig-
nature), and FARM (findings, assessment, recommendations or resolutions, and man-
agement). Other examples of structured formats include drug-related problem, ra-
tionale, plan (DRP); data, assessment, and plan (DAP); and drug-related problem,
data, assessment, and plan (DDAP). TITRS is an assessment approach, and FARM
places importance on monitoring, but these formats are not common among phar-
macists’ documentation and therefore are not discussed in greater detail. The SOAP
note is an interventionist approach and considered the standard for most if not all
health care providers, including pharmacists.1,6-8
Each style of structured or unstructured noting has advantages and disadvan-
tages but should be consistently used in the most effective and efficient manner.
Unstructured notes are seen more commonly with traditional manual documenta-
tion, and as the name implies, they are free in form, with appropriate language and
chronology. Advantages of this style are that the notes can be written expedi-
tiously while still providing a solid, high-quality, general overview. One disadvan-
tage is the note may be incomplete and inconsistent, which limits communication
to other health care professionals, leaving practitioners vulnerable to liability. This
type of documentation, whether it be manual or electronic, is usually reserved for
phone messages and informal communication between practitioners regarding on-
going patient care issues secondary to the limitations.1,6,7
To be more complete the majority of manual and electronic documentation
follows the systematic approach, allowing for completeness, consistency, and orga-
nization. Without a systematic structure, the documentation of the encounter may
be time consuming and confusing, especially in regards to the placement of infor-
mation from different sources. An example of this can be seen when documenting
height, weight, and allergies. One clinician may document this information in the
subjective findings, and another may place the information within the objective
data collection section. The primary determinant for where this information should
appear is how the information was collected. Was the information patient reported
(subjective) or clinician measured (objective)? This problem may not be as apparent
with an electronic documentation since many of the templates allow data to be
entered only in certain fields of the encounter note, creating semistructured docu-
mentation. This blends different styles for which some fields are more standardized
and others are free text. Like unstructured documenting, semistructured documen-
tation may also lack the quality and consistency of the standardized SOAP note.
Semistructured noting may be best used when triaging or forming a general impres-
sion for referral with no specific action needed by the pharmacist, much like a
8 Chapter 6

phone message or reporting of a lab result to the collaborating practitioner.

The more structured SOAP note format is appropriate when follow-up and moni-
toring are required as well as showing continuity of care provided by the health
care practitioner. Both of these documentation styles have been used routinely with
written communication and now are slowly being integrated as standards for the
majority of EMRs.1,6,7,10 This is especially true of the SOAP format since it is the
primary form for which payers traditionally reimburse.
No matter the format or style, documentation should always be used to demon-
strate the impact of your interventions to improve patient care and the overall
management of the chronic disease state(s). In addition, the documentation needs
to support and allow for reimbursement. All documentation should be complete,
complementary, compelling due to supportive evidence, and standardized and sys-
tematic to complement the oral communication among providers. Furthermore,
documentation should reflect patient agreement with the care plan among multiple
providers in terms of medication reconciliation, data collection, continuity of care,
and the transitioning of care along the continuum.1,6-8,11,12
Knowing this makes it much more apparent that documentation is more than
completing forms or capturing data during a patient encounter. No single ideal
format can encompass all patient interviews, yet documentation can still provide
evidence of the pharmacist’s interventions in advocacy and patient management.
An example SOAP note (Figure 5-1) illustrates a standardized, structured approach
to documentation and medication reconciliation, which will be discussed shortly.
(Example SOAP Note)

The four distinctive sections of a SOAP note are outlined as follows:1,6-8

1. Subjective: symptoms, information, and answers to provider questions that

the patient verbally expresses or that are provided by a caregiver. These
descriptions provide a clinician with insight into the severity of a patient’s
condition, the level of dysfunction, illness progression, and degree of pain.

2. Objective: measurements that are observed (seen, heard, touched, smelled)

by clinician or that can be tested. Examples include vital signs, pulse, tem-
perature, skin color, edema, and diagnostic testing.

3. Assessment: a prioritized list of assessed conditions. Simply stated, it is

what you think are the patient’s issues or problems from your perspective as
a pharmacist provider. This may consist of a level of control, differentials,
potential confounders to control, pertinent positives or negative signs and
symptoms related to the condition, reference to evidence-based medicine
(EBM), considerations for pharmacotherapy, and adjunctive lifestyle mea-
sures.

4. Plan: care plan action steps for the patient and health care practitioners.
The plan consists of the actions that you initiate or suggest to improve or
resolve the issues or problems identified in the assessment. This may in-
clude requests for additional laboratory or diagnostic assessments, alterations
Communication and Documentation for an Ambulatory Practice 9

in pharmacotherapy, lifestyle recommendations, standards of care, special

directions, referrals, self-monitoring, emergency contacts, and time for fol-
low-up appointments.

Date: XX/XX/XX Time In: 10AM

Pharmacotherapy Note:

S: MM is a 51 YO WM who presents for follow-up regarding his diabetes self-management

education (DSME) and follow-up A1C. MM will begin group support classes (part 1 and
2) at the DERC in January. MM does not have a PCP provider at this time since he does
not have insurance. He began a new job this month and hopes to have insurance within the
next 90 days. Patient does not report any complaints today.
PmHx: Type 2 DM (since June 2009)
Melanoma on forehead
ALL: NKDA
CVD risk factors (–) tobacco (+) HTN (+) DM (+) Low HDL (–) FamHx Ht Dz (+) age
(M>45, W>55) = 4 risk factors (1 CVD equivalent)
DM (–) polydipsia, (–) polyphagia but has some increased polyuria last week when
starting his new job. Nocturia x 0-2. (–) episode(s) of hypoglycemia since last visit.
(+) tingling in wrist and calves, (–) burning, and numbness of extremities or cramping. Pt
reports (–) edema
HTN: (+) HA 2 days ago resolved with ibuprofen and rarely occurs (–) dizziness, (–) chest
pain. Trying to keep sodium intake <2g/d.
Trying to follow dietary recommendations (low in sat fat, trans fats, more complex carbs
and higher fiber): eating three meals a day. Will review food labels and carb counting in
DSME classes.
Soc Hx: (–) Tob, never smoked (–) EToH, (–) illicit drugs, (+) caffeine (1 cup tea in AM
with skim milk and sugar subst), not exercising right now due to left toe amputation in
June. Works at a hotel and recently changed location, as an auditor on 11-7P M shift.
SurgHx: Left toe amputation (due to DM or other factor)
SMBG: per patient log (10/10-10/13): (FBG only) (133–144). No readings above 140
mg/dL.
Standards of care:
Podiatry appt: to be scheduled Optometry appt: to be scheduled
Immunizations: flu shot and pneumo needed, refer to health department
O: Sex: M HT: 68 in. WT: 193 (Previous 197, 202) Race: Caucasian
BMI: 30 (category I)
BP: 148/56 (no HTN medications taken today, caffeine within 30 min of appt)
(Prev) 114/76, 112/72 mmHg
P: 100
PPBG: 122 mg/dL (ate cereal at 8:30 AM) Prev FBG: 8/17 (184, 1 hr PPBG)
Previous labs: 7-09 (fasting or nonfasting)
K: 4.3
LFT: WNL
Scr: 0.73

Figure 5-1. Example SOAP Note (written by SL Haines).

10 Chapter 6

Lipids: WNL, except low HDL 21 mg/dL

Date: XXX (fasting)
TC: 145 TG: 135 LDL: 97 HDL: 21
EsGFR: (7/09) 148 (CG), 120 mL/min (MDRD)
Microalbuminuria (UACR): not assessed
A1C: 5.7% (12.2% [7/10/09] when hospitalized/diagnosed)
Outpt medications: (medication reconciliation documented and verified)
Metformin 500 mg PO BID (taking)
Glipizide 5 mg PO daily (taking)
Clonidine 0.1 mg PO TID (not taking)
Lisinopril 20 mg PO BID (not taking)
Omeprazole 20 mg PO daily (not taking)
OTC
Recommend ASA 81 mg PO daily (has not been taking)
Herbals
None
A: 1. DM: Controlled based on SMBG log, hyperglycemia symptom improvement and A1C
today. Needs education reinforcement for meter instruction technique and importance
of checking BG twice a day before breakfast and 2 hr after meals. Needs
comprehensive annual foot exam and assessment for microalbuminuria, retinopathy
assessment, annual influenza, and low dose ASA. (Goal FBG 70-130 mg/dL,
PPBG<180 mg/dL, HbA1C<6%-7% without causing hypoglycemia)
2. HTN: Uncontrolled based BP today in clinic. Patient with adverse effects associated
with clonidine: sleepiness, lethargy, dizziness. Inappropriately stopped his lisinopril
due to poor knowledge regarding medications. (Goal<130/80 DM)
3. Lipids: Controlled based on recent lipid panel with the exception of his HDL. (Goal
TC<200 mg/dL, TG<150 mg/dL, HDL>40 mg/dL, LDL<100, optional goal <70
mg/dL)
4. ADHERENCE: Expected level of patient adherence is: good

P: 1. Discussed the importance of checking blood glucose at least BID and provided log to
report values. Provided pt education videos on foot hygiene, meter use, and exercise
at home.
2. Discussed the s/sx of hypo/hyperglycemia and what to do should they occur.
Confirmed technique for meter instruction and will reassess in 3 months.
3. Reviewed all medications (provided med list) with patient and discussed reinitiation
of lisinopril. Will reinitiate lisinopril at low dose 20 mg 1/2T PO daily (10mg) and
reevaluate for titration when RTC in 2 weeks.
4. Continue current dose of metformin 500 mg PO BID with meals, ASA 81 mg PO
daily, glipizide 5 mg PO daily before breakfast. Discussed side effects to look for
regarding his medications.
5. Encouraged to continue low-fat, low-cholesterol, moderate CHO diet (130-150 g/d).
Reinforced importance of physical activity as tolerated with his amputation and
contingent on provider approval. Alternatives are swimming, stationary bike, as well
as reinforcing principles of the DASH diet and TLC to help improve HDL.
6. Refer to NP today for comprehensive foot exam and health department for flu shot.
7. Will notify Dr. X (physician) of the pending blood work and assessment today.

Figure 5-1. Example SOAP Note (written by SL Haines). (cont’d)

Communication and Documentation for an Ambulatory Practice 11

8. Will need f/u lipid assessment in November, microalbuminuria assessment, A1C in 3

months and should be screened for colorectal cancer.
9. Call with any problems
Follow-up standards of care
1. Podiatry q 6 months
2. Dentistry q 6 months
3. Optometry q 6 months
4. Nutrition prn

Signature

Seena Haines, PharmD, BC-ADM, CDE

Pharmacotherapy Specialist
Diabetes Education and Research Center

Time Out: 60 minutes spent counseling/coordinating care

Total Time Spent: 1 HR

Figure 5-1. Example SOAP Note (written by SL Haines). (cont’d)

Additional considerations when documenting patient care can be obtained from

the ASHP Guidelines on Documenting Pharmaceutical Care in Patient Medical Records, Guidelines on
a Standardized Method for Pharmaceutical Care, and Table 5-1 provides other characteristics
for documentation in an EMR/PMR.6,7

Table 5-1. Example Items for Documentation in an EMR/PMR1,7,9

Chronological Marker Date and Time
Summary of Medical History CC (chief complaint)
HPI (history present illness)
PmHX (past medical history)
SocHx (social history)
FamHx (family history)
SurgHx (surgical history)
ALL (allergies/reaction)
Medications/OTC/herbals
PE/ROS (physical exam/review of systems)
Laboratory indices/diagnostic procedures
Oral/Written Consultations From other health care professionals (HCP)
Oral/Written Orders From physician or other HCP
- start and stop dates
- precautions
- drug interactions
- protocols
Medication Changes Adjustment of dose, route, frequency or form
Intended use
12 Chapter 6

Table 5-1. Example Items for Documentation in an EMR/PMR1,7,9 (cont’d)

Chronological Marker Date and Time
Drug-related Problems Actual and potential
- drug-drug
- drug-food
- drug-lab
- drug-disease
Assessment and Plan Interventions and professional judgment
Therapeutic Monitoring Rule out duplication
Expected adherence
Pharmacokinetics
Adverse events/toxicity
Clinical resolution/symptomatology
Patient Education Therapy related
Adjunctive measures
Self-monitoring
Etiology and progression of disease
Identifiers Person(s) involved
Documenting pharmacist
Aesthetics Indelible ink
Nonalterable (electronic)
Policies Code of ethics
HIPAA
Reimbursement CPT codes: 0115T, 0116T, 0117T
ICD-9 and Evaluation and Management (E/M)
Time in and out, total time spent/rate of service
E/M Medicare standards

The SOAP note is an example from a patient-pharmacist diabetes self-manage-

ment educational encounter in a specialized outpatient ambulatory multidisciplinary
diabetes practice. The structured note lists the assessment and plan separately; al-
ternatively, they may also be combined. Both are suitable forms of documentation
for reimbursement, and the choice is left to clinician preference or documentation
procedure unique to your individual practice site.
SOAP notes can be kept in a PMR for ease of documentation for follow-up visits
or in a patient registry to expedite data collection and report clinical indicators.
Alternative styles of structured notating can also be integrated with the use of an
EMR through a variety of manufacturers as discussed. These alternative styles are
contingent on the care setting, funding support, your preferences and access, as
well as the structure of your practice site. Some may have the ability to adopt
pharmacy-based software for documentation, and others will use the software cho-
sen by their practice site administrators and purchased by their health system. (Com-
munity-Based Clinical Pharmacy Documentation Software–Table)
Even as electronic information resources (EMR/EHR) gain momentum, it is ap-
parent many practices will still rely on paper and pen for manual documentation.
No matter the form, the same documentation principles apply, and the information
Communication and Documentation for an Ambulatory Practice 13

contained in a PMR serves as justification for reimbursement, a legal permanent

health record, and a quality-assurance tool for practice standards.1,7,8

Documentation Elements
Medication Therapy Management Community-Based Core
Components
The ability to bill for pharmacist services took effect under medication therapy
management (MTM) provision of Medicare Part D.16 A community-based MTM
model was developed in July 2004 under the partnership of several pharmacy orga-
nizations and published through the American Pharmacists Association and Na-
tional Association of Chain Drug Stores. Managed care health systems and payers
have acknowledged that pharmacists provide consistent, cost-effective, clinical ser-
vices that improve patient outcomes and reduce health care expenditures.18-20 Effec-
tive in January 2006, pharmacists were recognized providers of MTM as defined
under the Medicare Prescription Drug, Improvement, and Modernization Act of
2003 (MMA) Part D Prescription Drug Benefit.13 It has been clearly recognized
that collaborative MTM can maximize patients’ health-related quality of life (HRQOL)
and reduce the frequency of preventable drug-related problems. In this team ap-
proach, drug therapy decision making and management are coordinated through
the collaboration of pharmacists, physicians, nurses, and other health care profes-
sionals. This framework identifies five core components: medication therapy re-
view, a personal medical record or list, action plan, intervention and referral, and
documentation with follow-up. These are the components you should use when
seeing patients, and you should discuss them with IT personnel when they are cre-
ating or defining the EMR templates for your patient encounters. MTM is a prime
example of why the manual chart and/or the EMR need to be altered to accommo-
date the pharmacists’ role in the patient’s care.20

CASE
By adopting the office templates for diabetic management and creating a
template specifically for anticoagulation visits, you were able to select
sections of the SOAP note that worked for your type of visits. You also
were able to prompt Dr. Busybee in your note when a patient was due for
preventive care visits and even immunizations. Adapting to the existing
documentation system also assisted the other practitioners in your office
to read and understand your plan of care for patients, which allowed for a
team approach to the care of the patient.

When you participate in collaborative MTM, you will document your activities
in a PMR that you make available to other health care professionals in a timely
fashion through established channels of communication.1,6,7,13 Since documentation
14 Chapter 6

standards vary state to state, you should develop and implement collaborative prac-
tice agreements, patient referral processes, and the practice settings in accordance
with the laws in your state. Please see Chapter 7 for more detail on collaborative
practice agreements.
HIPP
PAA A S a f e t y M e a s u rre
es
The issue of patient confidentiality and security of documented medical informa-
tion continues to be debated and discussed. This has been especially relevant in the
transition to electronic media for the majority of the patient’s medical information.
Details on what an organization or provider must do to meet HIPAA requirements
are lacking, but the law does state that health care organizations must “implement
physical safeguards for all workstations that access electronic protected health in-
formation, to restrict access to authorized users.” As a provider, you are expected to
log out when leaving a workstation, use a privacy screen to prevent viewing by
unauthorized people, and remove workstations from high traffic areas.21 In response
to these measures, it is important that you have your own access code, whether it is
a password or biometric fingerprint, so that electronic media is secure. Also, you
should not electronically document “under” a physician or nurse practitioner who
may see the patient at the same appointment since this does not reflect your en-
counter and could lead to confusion over your assessment and plan for the patient.
In addition, students should be blocked from entering any data into the system
without your approval and signature. Maintaining patient privacy is critical. If
needed, you may wish to provide some basic training to students and others on the
inappropriateness of discussing patient information in hallways, elevators, at lunch,
or even with others not working at the site. It is a good idea to have all health care
providers visiting the practice, including students, residents, technicians, etc., sign
a confidentiality statement regarding patient information.
All medical records must be maintained in a safe and secure area with safeguards
to prevent loss, destruction, and tampering. Your documentation within the medi-
cal record may physically exist in separate and multiple locations in both paper-
based and electronic formats, depending on the practice site(s). However, chronol-
ogy is essential, so pay close attention to ensure that documents are filed properly
or the information is entered in the correct encounter record for the correct pa-
tient, including appropriate scanning and indexing of imaged documents at all prac-
tice site(s). All PMRs are retained for at least as long as required by state and federal
law and regulations and must be maintained in their entirety regardless of form or
format. Note that federal law supersedes state law unless the state is stricter than the
federal government. Written or electronic, no documentation entries may be de-
leted from the record except in accordance with the destruction policy. If your
written PMR is microfilmed or kept on a computer database, there should be a
written policy at your site concerning PMRs, outlining who is custodian and where
the original PMRs are stored. This type of record keeping is crucial as offices imple-
ment EMRs yet must maintain the outdated written chart as required by state law.22
HIPAA waivers have language requesting patient consent regarding the collection
of information, use in research, and disclosure of patient’s personal information as re-
quired. This also includes who will be sharing in the information, patients’ right to
Communication and Documentation for an Ambulatory Practice 15

access their own information (medication list, lab results, and list of diagnoses), and the
patients’ right to submit a complaint. In addition, print or electronic documentation
must be stored appropriately to ensure confidentiality. Patients also need to consent
when clinical documentation and other health information is transferred to other pro-
viders. No matter what system is used for storage of information, access should be moni-
tored and limited to only those clinicians directly involved with the patient’s care.23
Documenting Medication Reconciliation
Medication reconciliation and verification of a current and accurate medication list
is arguably one of the more important documentation activities performed to main-
tain patient safety and improve patient outcomes for any transition of care. Medica-
tion reconciliation reduces errors in transcription, omission, duplication of therapy,
indication for use, and drug-drug and drug-disease interactions.24 The simple act of
comparing the drugs that the patient reports taking at home against a recently
documented medication administration record (MAR) in either an office or institu-
tional setting allows a cross-check and can help alleviate the approximately 4.7% of
hospital admissions linked to adverse drug reactions. In addition, the impact made
possible by pharmacists performing this role will help to create opportunities to
build collaborative relationships with other health care professionals and patients.25
We are focusing on medication reconciliation because its importance extends
beyond the setting of patients entering and leaving the hospital. As we know, the
transition of patient care to the outpatient setting and among the various ambula-
tory providers allows gaps in information, especially since most outpatient sites are
not linked with each other or with extended-care facilities, health systems, and
their hospitals. Additionally, significant errors occur secondary to the many modi-
fications to medication dosages, over-the-counter (OTC) use, and adherence issues
patients experience that are often seen by ambulatory pharmacists in their daily
practice. Taking responsibility to resolve or prevent these types of errors is what
makes medication reconciliation the backbone of pharmacy clinical services. Your
expertise lends itself to a thorough and detailed medication history that is then
documented in the PMR. Documentation is essential for medication reconciliation
to be effective. It should not stop at the medication list, as records regarding side
effects, allergies, drug interactions, and cost issues are often as important as medica-
tion history for optimal care of the ambulatory patient.1,6,7,25,26
The EMR creates a new dimension in medication reconciliation and medication
list collection and storage. However, the record is only as strong as the accuracy of
what is being documented. In most cases, the ability to transfer the list electroni-
cally to another system does not exist. Gaps remain in documenting medication use
in the majority of EMRs. Ernest and colleagues illustrate as many as one of every
four medications was associated with discrepant information in the patient medical
record.28 Emphasis has been placed on transition to and from inpatient care, but as
previously mentioned, this needs to be taken further by those of us practicing in
the outpatient setting. Methods to ensure accuracy and transferability of the medi-
cation lists in both the electronic and paper format need to be developed, imple-
mented, and maintained and measured for accuracy.27 Content standards need to be
developed and agreed upon to enable interoperability.
16 Chapter 6

No matter if the documentation system is electronic or manual, medication

reconciliation should occur at each office visit and include all medications, not just
those associated with a particular visit. Pharmacists play a key role in preventing
medication errors and enhancing care by simply documenting and updating medi-
cation records on a continual basis.27

Communication Techniques
Documentation using a clinical encounter note is an effective way to communicate
what has occurred at an office visit. Documentation is only as strong as the data
gathered, thus it is very important for you to also effectively communicate with
your patients during the visit. Employing communication techniques, such as moti-
vational interviewing or assessing the patient’s health care literacy level, will aid
you in gathering the most useful information from your patient. Good communica-
tion will enable you to synthesize and analyze (assessment) the information gath-
ered to create a specific plan for care that meets the patient’s needs.

CASE
Over the last 6 months, your practice continues to grow as other patients
and providers of the practice hear about your service. You approach Dr.
Busybee about expanding the services you provide by offering to include a
formal medication reconciliation services and assessment of each
patient’s health care literacy level. Since this does not conflict with the
office process or the original business model, Dr. Busybee sees this as a
win-win for his office and his patients and approves you adding these
services to your office hours. You are pleased with his vote of confidence,
but realize while medication reconciliation seems easy, some questions
remain: what do I need to be effective at performing these new services
and how will I document my impact?

Communication Tips
Establish rapport early in the encounter with your patient through a welcoming
introduction to you and your clinic. Patients can easily sense authenticity in their
providers, so most importantly you should be relaxed, confident, and attentive to
the patient and the encounter. After ensuring that you and your patient are com-
fortable and ready to start the visit, conduct the interview with open-ended ques-
tions. Doing so enables patients to tell you their health care story in their own
words. It is important to frequently pause and summarize or reflect back to the
patient so that you may verify accuracy and your correct understanding of the
patient’s story. Listening is an important communication tool. Documentation of
the encounter can include subjective and objective findings that employ the “basic
seven” line of questioning. Other question series commonly used are the Indian
Communication and Documentation for an Ambulatory Practice 17

Health Service Counseling Model, the PQRST method, and QuEST Scholar
method.28,29 All of these can be found on the web site section corresponding to this
chapter.
Motivational Interviewing
Motivational interviewing (MI) is an effective technique that can be incorporated
into the patient interview process. Developed in 1991 by Miller and Rollnick, MI
uses a patient empowerment approach throughout the encounter.30 Although MI
and another interview style called the transtheoretical model (Prochaska and colleagues,
developed in 2004) were developed independently; there is some similarity be-
tween them.31 Both assume that people approach change with varying levels of
readiness. Historically, MI has been used for patients with drug and alcohol addic-
tion and works from the assumption that many patients who seek therapy are am-
bivalent about change, but their motivation changes during treatment. The four
basic principles of MI are as follows: (1) express empathy, (2) develop discrepancy,
(3) roll with resistance, and (4) support self-efficacy. As a pharmacist, you can as-
sume the role of patient mentor or coach to aid patients in making behavior changes
by creating “self-selected” patient goals. Documentation should include these goals,
which use the SMART acronym: specific, measurable, attainable, realistic, and time-
bound relative to behavioral and lifestyle modification.32 A great clinical example of
how to use MI is in smoking cessation. By helping the patient create goals and then
working with him or her on the appropriate pharmacologic management choices,
you can play a large role in assisting your patient to kick the habit.
Health Care Literacy
As discussed, there are a number of best practices that apply when conducting a
patient encounter, but no matter which communication technique is employed,
you must have an understanding of the patient’s level of health literacy. Health care
literacy is defined as “the degree to which individuals have the capacity to obtain,
process, and understand basic health information and services needed to make ap-
propriate health decisions.”33
The National Assessment of Adult Literacy (NAAL) provided the first measure
of U.S. health literacy. Survey findings showed 14% of U.S. adults function at
below the basic level, 22% function at the basic level, 53% have an intermediate
level of health literacy, and 12% have proficient health literacy. Note that inter-
preting medication labels requires intermediate skill. This means that 36% of adult
Americans have levels of health literacy below what is required to understand typi-
cal medication information.34 Low health literacy is a problem that touches all groups
and segments of our society (elderly, minorities, homeless, poor, poorly educated,
etc). Several studies have assessed patients’ understanding of their medications. In-
dividuals with limited health literacy demonstrated 12–18 times the odds of being
unable to identify their own medications and distinguish one from the other. Pa-
tients who have difficulty understanding simple instructions such as taking a medi-
cation every 6 hours or on an empty stomach have insufficient understanding of
common drug mechanisms and side effects and greater misinterpretation of drug
warning labels.35–40
18 Chapter 6

Several tools are available to analyze the readability of patient education mate-
rials. Examples include the Flesch-Kincaid Grade Level and Reading Ease and the
Simple Measure of Gobbledygook (SMOG) index. There are also resources to test
the health literacy of those who need it, such as the rapid estimate of adult literacy
in medicine (REALM) and the test of functional health literacy in adults (TOFHLA),
which are validated instruments. Additional assessments available are the tools for
real-time assessment of health information literacy skills (TRAILS) and the newest
vital sign (NVS) by Pfizer’s clear health communication, as well as those from Medline-
Plus, National Institute for Literacy (NIFL), Plain English Network, the American
Medication Association (AMA), and Harvard School of Public Health. The Agency
for Healthcare Research and Quality (AHRQ) has a Pharmacy Health Literacy Assessment
Tool User’s Guide on their web site to assess health literacy for pharmacies and has a
survey accessible through the public domain.43

All patients can benefit from five recommended strategies

for patient-centered visits:35,42,43
1. Use plain language and avoid medical jargon and vague
instructions.
2. KISS (keep it short and simple). Tell patients what they
need to know.
3. Ask patients to “teach back” what they have learned.
4. Recognize variation in learning styles and preferences, thus verbal
messages should be reinforced with written information and images.
5. Everyone learns better if information is reinforced in multiple ways.

Once literacy level is established, it is essential to document the information

within the PMR to assist everyone who is caring for the patient. This is true for both
health care literacy and literacy skills in general, including English as a second
language (ESOL) and learning disabilities.42,43 Many times pharmacists are the only
ones assessing literacy because we are asked to consult on the nonadherent patient
or the patient who cannot seem to use medications correctly. Before you accept
that the patient is voluntarily nonadherent, assess literacy level, language skills, and
any apparent learning disabilities to determine if they play a role in problems the
patient is experiencing. That simple act will make you a hero in the patient’s eyes,
but it will also affect how they are cared for by others as well as the communication
style when educating the patient at future encounters.

Medical Liability and Auditing

Performance Evaluation
The scope of professional liability has increased parallel to the increase in pharma-
cists’ scope of practice. Historically, pharmacists have functioned and intervened as
learned intermediaries under the direct supervision of a physician’s verbal or written
orders. This paradigm shift of pharmacists practicing as independent providers places
Communication and Documentation for an Ambulatory Practice 19

more responsibility on pharmacists as medication therapy experts, thus documenta-

tion of care is essential to protect pharmacists from liability.1

CASE
It has been 1 year since you submitted your business plan to Dr. Busybee.
At three months he reminded you that he expected evidence of the impact
you have had on his patient population. At that time you began using the
EMR to track HgbA1c levels and INR trends for your patients. When you
added medication reconciliation and health literacy screening to your
service, you expanded your metrics to include compliance checks as well
as number of admissions to the local hospital due to a diabetes and/or
anticoagulation complications. Using the EMR you were able to show
percentage of your patients that achieved treatment goals including
compliance with medications, appointments, and lab work. Dr. Busybee
was impressed and shared your impact with his partners, who in turn used
the local trends to gauge your impact versus patients who did not have
access to a pharmacist.

Awareness of this trend shows that it is vastly important that every pharmacist
who participates in direct patient care and documents in the PMR have a mecha-
nism in place that tracks performance, continuous quality improvement, and adher-
ence to practice standards. For those using an EMR for documentation, they may have
potential for greater ease of measuring ambulatory care-based quality outcomes and
errors; however, all clinical documentation can be used to track impact of care.44
Outcome tracking mechanisms need to be developed using proper documentation
that allows for a standardized approach to find and apply patient data to determine if
quality standards have been achieved. Integrating pharmacy service benchmarks into
a PMR will require a close look at how it can be used to document the effectiveness of
pharmacy services and possibly justify expansion of resources and personnel. You
should be planning ahead to determine the capabilities of the PMR format used by the
practice so it can be designed to find and track your documentation easily, by using
certain parameters. This was alluded to in the first part of the chapter regarding how
to create your templates for each of your patient encounters. That upfront research
and implementation will pay off as you set up your continuous quality improvement
(CQI) and performance measures for your practice.
An EMR note could be applied to assessing CQI by looking at how point-of-
care testing is documented within your electronic encounter note. With the EMR,
only certain fields of the note may be included in parameter searches, but by creat-
ing the right template and choosing the correct field, you should be able to track
and graph INRs to illustrate your success in keeping patients with the therapeutic
range. Another example of using the EMR is to highlight potential problems before
they occur, such as searching a database for patients with diabetes who take metformin
and cross reference that information with serum creatinine levels. This type of qual-
20 Chapter 6

ity assurance initiative will aid in identifying at-risk patients with a potential for an
adverse drug event before it happens.44
As we have discussed, some EMRs are more robust than others, so it is impera-
tive to discuss with IT personnel how such information can be gathered and format-
ted in a searchable field.
Chart Audits
One question that is frequently asked is who will be setting up and evaluating phar-
macists’ performance. Audits are a tool used by ambulatory professionals to assess if
an office is meeting designated thresholds for quality. Audits help deviations from
standards in patient care and documentation in the patient care process. Many phar-
macists have never heard of chart audits. However, with the greater emphasis on
quality in health care reform and as we assume the role of independent practitio-
ners, all pharmacists need to develop a protocol and have procedures in place to
monitor the quality of services. Thorough documentation of patient care encoun-
ters and compliance with CMS standards are key in meeting standards set forth by
you and your practice site. You may wish to perform quarterly chart audits and
report on what you and your organization consider to be important performance
evaluation parameters.

CASE
Since you were able to show an impact for Dr. Busybee’s patients, many
of his partners have started referring patients to you for care. Realizing
you are taking on more responsibility, you approach Dr. Busybee and ask
how he keeps track of his impact. You inquire if there is a way to assure
you are providing the appropriate care, not just metrics or outcomes. Dr.
Busybee suggests that you become integrated into the chart audit
protocol the physicians and nurse practitioner use in the office to assess
quality of care.

Audits are commonly conducted through peer evaluation where each member
of the outpatient clinical team reviews the PMRs of colleagues using a predeter-
mined set of criteria and threshold quality markers. Areas of emphasis may include
appropriate labs ordered, medication reconciliation, monitoring parameters, level
of patient adherence, preventative measures, screenings, or clinical outcome mea-
sures and goals. This applies to all midlevel providers and all remote sites where you
practice, thus your audit does not have to be done by another pharmacist; it can be
done by other clinicians in the office. Audit procedures are often handled by a
continuous quality (CQI) committee. They create the parameters from established
standards and billing requirements that are used in auditing the various providers.
The purpose of a chart audit is to provide feedback to the clinician to improve
patient care, improve accuracy of information recorded, and to ensure thorough
documentation practices.1 (Auditing Tool)
Communication and Documentation for an Ambulatory Practice 21

The key points you should consider in the peer review process are as follows:45
• Placement of blame, finger-pointing, and conflicts with other caregivers
should be resolved through the quality improvement process and does not
belong in medical record.
• Subjective terms should be avoided. Subjective opinions by physicians and
nonphysician clinicians (NPC) open up liability issues. Documentation
should be as factual as possible.
• Hospital staff, facility, or equipment concerns should be addressed in an
incident report completed by the hospital administration.
• Do not document conversations with the attorney, insurance carrier, or risk
manager in the medical record. If necessary, document separately.
• Incident reports can be protected from discovery if they are part of a peer-
review process, although they can be discovered through a review of the
medical record when attorneys become aware of their existence. Likewise,
chart audits can ensure adequate coding and complexity to protect against
fraud and liability with CMS.
The key points you should consider in the chart audit process are as follows:
• Look for under- or overdocumentation in your charts that can raise flags for
improper coding selection.
• Ensure that appropriate levels of service are identified and billed.
• Learn the proper steps for choosing appropriate levels of history, exam, and
medical decision making (evaluation and management codes are discussed
in Chapter 7).
• Get the chart audit forms to implement your internal audit program.
• Learn how to audit based on coding facts and potentially uncover missed
revenue.
• Make the chart audit an essential component of the compliance plan.

Professional Liability
Liability, as it relates to clinical documentation, can be an issue when (1) payment
challenge is ensuing for service rendered or not rendered or (2) legal action is
ensuing as a result of an action or nonaction taken by the provider. In both situa-
tions, your documentation will provide the necessary information to manage the
process discovery and review of professional conduct.1

The importance of good documentation cannot be any more

important than when you are defending your decisions and
actions regarding patient care.
22 Chapter 6

This means that documentation must be accurate and organized. By any means,
you want to avoid any activity that can be misconstrued as fraud. By CMS defini-
tion, fraud is “the intentional deception or misrepresentation that an individual
knows to be false or does not believe to be true and makes, knowing that the decep-
tion could result in some unauthorized benefit to him/herself or some other person”
or “to purposely bill for services that were never given or to bill for a service that has
a higher reimbursement than the service produced.”46

This definition drives home the point that what we document

needs to be accurate, factual, and thorough, since we are all
aware that if the chart does not reflect the care given, then
the actions never happened according to our legal system.

Historically, we have acted as record keepers for medication use as well as drug
interactions and adverse drug events. Now our documentation standards have been
adjusted and expanded to show the care we provide as health care practitioners.
A key element that all documentation should include is the assessment of the
situation within the realm of care given. If you cannot address the problem, or it is
out of your scope of practice, there must be documentation of how other health
care team members (referring provider or interdisciplinary colleagues) were involved
to address the needs of the patient. In addition, your plan of action must be concise
yet complete. The ideal documentation includes how you affected care, planned
for upcoming visits, and intervened to provide preventive care. For an example,
refer back to the SOAP note and notice how part of the plan was to have the patient
follow up with certain specialists (standards of care) as outlined by the ADA guide-
lines. Many pharmacists forget that as a patient advocate you have the power to
ensure appropriate care is given to your patient. By communicating thoughts, ac-
tions, and plans for the patient, you can assist the next member of your team to
provide high-quality care and protect yourself and others from liability.1,6,7

Chapter Summary
As you can see, documentation plays a vital role in your everyday professional life.
It allows communication between you and other health care practitioners while also
providing evidence of what occurred during the patient encounters. Don’t forget
that multiple providers impact a patient’s care, thus you must continue to develop
your communication skills not only with other health care providers and patients
but also with each other.
Health information technology is being implemented faster than most realize
and, while this advancement has its disadvantages, the one area of improvement will
eventually be communication between and within health systems. Electronic docu-
mentation is the future; by allowing practitioners to collect patient history, reports,
prescription information, and reimbursement data, this format will continue to push
for proper and thorough documentation so all health care providers can make the
Communication and Documentation for an Ambulatory Practice 23

most informed clinical decisions possible for patients. In the end, documentation is
an essential component to a successful partnership between providers regardless of
their degree, location, or specialty.

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Communication and Documentation for an Ambulatory Practice 25

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Web Resources
Auditing Tool
Example Documentation Elements for EMR/PMR
Examples of Community-based Clinical Pharmacy Documentation Software
Example SOAP Note