These procedures will ensure consistent collection and updating of allergies, medical conditions, medication indications, and counselling note

To : All Staff

For All Patients

Please ensure the following information is documented in their profile

• Allergies and Intolerances
• Medical Conditions

To facilitate the collections of this information, please ask patients to complete the Patient Intake form *while waiting.  Update patient’s file once the form is completed.

Refill Prescriptions

Ask and document the following information

• New allergies or reactions
• New medications (OTC, supplements)
• Change in health status
• Effectiveness and tolerability of current medications

To: Pharmacists

Clinicviewer

Review of Clinicviewer for high risk patients, including those with;

• >4 chronic medications
• Diabetes, cardiovascular disease, renal/hepatic impairment, cancer, transplant, autoimmune diseases
• High risk medications including anticoagulants, hypoglycemics, opioids and high risk analgesics,  immunosuppressants, antipsychotics and medications with narrow therapeutic index.
• Frequent hospitalization
• Adherence issues
• Pregnancy or breast feeding
• Unclear indications

Use this information to confirm indications, identify medical conditions and identify any concerns. 

Documents “Clinicviewer Reviewed” in patient’s file.

To: Pharmacy Manager

Ensure all staff are trained on this SOP.  Conduct review of files every 3 months to ensure policy is adhered to and address non-compliance if necessary.  Audit can be reduced to every 6 months if no issues are noted. Targets are as follows

Audit Item	Target / Standard
Allergies documented	≥90% of profiles
Medical conditions documented	≥90% of profiles
Indications documented for all medications	100% of new and high-risk meds
Counselling / assessment notes	Present for ≥80% of refills
Refill patient assessment done	≥80% of refills
High-risk patient assessment documented	100%
Clinical Viewer used when applicable	Documented in ≥90% of relevant cases
Documentation format consistent	All notes follow SOAP/DAP or structured template
Follow-up actions recorded	All issues addressed or scheduled

Documentation Methods

Please enter information in a structurized format using either DAP or SOAP .

Clinical Notes

Clinical Notes allow you to document discussions with a patient or information about a patient such as consultations, drug related problems, adherence, follow-ups and immunizations on a Patient Folder.

These Clinical Notes provide you the ability to link these notes directly to a prescription and document any data, assessment and plans that you’ve discussed with a patient.

If a follow-up is recommended based on these conversations, it can be scheduled directly from the Clinical Notes window and is automatically added to the Activities tile.

To add Clinical Notes:

1. Search for and select the patient.
2. Select the Clinical tab.
3. Under Clinical History, select Add.The Clinical Notes window appears. 
4. From the Type dropdown, select the type of clinical note being added.
5. Optional – enter information into the remaining fields of the Clinical Notes window.
6. Select OK. The Clinical Notes window closes to the Clinical tab.Once OK is selected, the clinical note cannot be edited.
7. Select Save.

Dialogue

To document counselling with respect to a particular prescription, open the patient’s profile.
Select ” RX ” then “Dialogue”

All dialogue documentation can be viewed in the Clinical Tab of the patient’s file

Medical Conditions

Enter any medical condition under the Clinical tab.
– Click “Add”
– Select “Condition”
– enter the medical condition and click “search”. If necessary use the wild character “%” to broaden the search
– Select the correct condition.