To facilitate the collections of this information, please ask patients to complete the Patient Intake form *while waiting.\u00a0 Update patient\u2019s file once the form is completed.<\/p>\n\n\n\n
Refill Prescriptions<\/h3>\n\n\n\n
Ask and document the following information<\/p>\n\n\n\n
- \n
- New allergies or reactions<\/li>\n\n\n\n
- New medications (OTC, supplements)<\/li>\n\n\n\n
- Change in health status<\/li>\n\n\n\n
- Effectiveness and tolerability of current medications<\/li>\n<\/ul>\n\n\n\n
To: Pharmacists<\/h2>\n\n\n\n
Clinicviewer<\/h3>\n\n\n\n
Review of Clinicviewer for high risk patients, including those with;<\/p>\n\n\n\n
- \n
- >4 chronic medications<\/li>\n\n\n\n
- Diabetes, cardiovascular disease, renal\/hepatic impairment, cancer, transplant, autoimmune diseases<\/li>\n\n\n\n
- High risk medications including anticoagulants, hypoglycemics, opioids and high risk analgesics, immunosuppressants, antipsychotics and medications with narrow therapeutic index.<\/li>\n\n\n\n
- Frequent hospitalization<\/li>\n\n\n\n
- Adherence issues<\/li>\n\n\n\n
- Pregnancy or breast feeding<\/li>\n\n\n\n
- Unclear indications<\/li>\n<\/ul>\n\n\n\n
Use this information to confirm indications, identify medical conditions and identify any concerns. <\/p>\n\n\n\n
Documents \u201cClinicviewer Reviewed\u201d in patient\u2019s file.<\/p>\n\n\n\n
To: Pharmacy Manager<\/h2>\n\n\n\n
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<\/p>\n\n\n\n
Audit Item<\/strong><\/td> Target \/ Standard<\/strong><\/td><\/tr><\/thead> Allergies documented<\/td> \u226590% of profiles<\/td><\/tr> Medical conditions documented<\/td> \u226590% of profiles<\/td><\/tr> Indications documented for all medications<\/td> 100% of new and high-risk meds<\/td><\/tr> Counselling \/ assessment notes<\/td> Present for \u226580% of refills<\/td><\/tr> Refill patient assessment done<\/td> \u226580% of refills<\/td><\/tr> High-risk patient assessment documented<\/td> 100%<\/td><\/tr> Clinical Viewer used when applicable<\/td> Documented in \u226590% of relevant cases<\/td><\/tr> Documentation format consistent<\/td> All notes follow SOAP\/DAP or structured template<\/td><\/tr> Follow-up actions recorded<\/td> All issues addressed or scheduled<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n Documentation Methods<\/h1>\n\n\n\n
Please enter information in a structurized format using either DAP or SOAP .<\/p>\n\n\n\n
Clinical Notes<\/strong><\/h3>\n\n\n\n
Clinical Notes<\/strong> 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<\/strong>.<\/p>\n\n\n\n
These Clinical Notes<\/strong> 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.<\/p>\n\n\n\n
If a follow-up is recommended based on these conversations, it can be scheduled directly from the Clinical Notes<\/strong> window and is automatically added to the Activities<\/strong> tile.<\/p>\n\n\n\n
To add Clinical Notes<\/strong>:<\/p>\n\n\n\n
- \n
- Search for and select the patient.<\/li>\n\n\n\n
- Select the Clinical<\/strong> tab.<\/li>\n\n\n\n
- Under Clinical History<\/strong>, select Add<\/strong>.The Clinical Notes<\/strong> window appears. <\/li>\n\n\n\n
- From the Type<\/strong> dropdown, select the type of clinical note being added.<\/li>\n\n\n\n
- Optional<\/em> – enter information into the remaining fields of the Clinical Notes<\/strong> window.<\/li>\n\n\n\n
- Select OK<\/strong>. The Clinical Notes<\/strong> window closes to the Clinical<\/strong> tab.Once OK is selected, the clinical note cannot be edited.<\/li>\n\n\n\n
- Select Save<\/strong>.<\/li>\n<\/ol>\n\n\n\n
![\"\"](\"http:\/\/www.akron.duonglam.ca\/wp-content\/uploads\/image-3-1024x640.png\")
<\/figure>\n\n\n\n![\"\"](\"http:\/\/www.akron.duonglam.ca\/wp-content\/uploads\/clinical-note-1008x1024.jpg\")
<\/figure>\n\n\n\nDialogue<\/h3>\n\n\n\n
To document counselling with respect to a particular prescription, open the patient’s profile.
Select ” RX ” then “Dialogue” <\/p>\n\n\n\n![\"\"](\"http:\/\/www.akron.duonglam.ca\/wp-content\/uploads\/image-2-1024x783.png\")
<\/figure>\n\n\n\nAll dialogue documentation can be viewed in the Clinical Tab of the patient’s file<\/p>\n\n\n\n
Medical Conditions<\/h3>\n\n\n\n
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. <\/p>\n","protected":false},"excerpt":{"rendered":"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 To facilitate the collections of this…<\/span><\/p>\n
- Under Clinical History<\/strong>, select Add<\/strong>.The Clinical Notes<\/strong> window appears. <\/li>\n\n\n\n