Pharmacists must be able to document accurately and effectively patient information in the patient's medical history , medica...
Pharmacists must be able to document accurately and effectively patient information in the patient's medical history, medication profile pharmaceutical, and other pharmacy records, and correspond with patients and other health professionals.
The patient's history is the main communication tool written for all health professionals. Health professionals in the outpatient setting writing progress notes after each patient visit or interaction. Health professionals who care for patients in the hospital setting write daily progress notes in patient charts. Writing in a patient's medical record (graphics) is a privilege granted by each institution or organization for professionals in individual attention. Many institutions and organizations give pharmacists privileges graphics, although this practice is far from universal.
The medical record is usually used for documenting and communicating information about the patient's progress; to assess, usually retrospectively, quality and appropriateness of patient care; and to document the activities and patient care services for remuneration. Healthcare professionals should comply with legal, ethical and professional standards in cataloging patient information. Black ink is photocopied more clearly than other colors and is recommended only if the patient record must be photocopied (eg a summons to a legal hearing or sent to health professionals outside the institution or practice). Clear photocopies reduce the risk of misunderstanding or misinterpretation of the information documented. Clear and legible handwriting is important. Errors are handled by deleting the error with a line and initial the error (eg misteakRS error). This format clearly documents the error and the person who changed the record is identified. Products Painting on machine or handwritten information not used in legal documents because they hide the error and could be used by anyone at any time to change the registry.
Document the factual information and restrict the assessments and judgments which correspond to pharmacists. For example, a pharmacist can learn during an interview patient's medication history the patient drinks a bottle of whiskey and a six pack of beer a day. It is convenient to document the facts, but inappropriate for the pharmacist to give the patient a diagnosis of alcoholism
Each note in the medical record contains a descriptive header (eg, clinical pharmacy, pharmacokinetics, nutritional support, assisting, cardiology consult), date and time of the note was written, patient-specific data and other inforCada note Patient Medical Record UN Headline Contains descriptive (FOR EXAMPLE, clinical pharmacy, pharmacokinetics, nutritional support, assisting, consult cardiology) The date and time the note was written, Specific Patient Data and other information, and the signature and Title Health Professional. The header identifi the type of information found in the note and enables Persons using the para table scan quickly Pages in finding Specific information. Sonmation date and time, and the signature and title of healthcare. The header identifies the type of information found in the note and lets people use the table to scan pages quickly search for specific information. The date and time are important details that put the information in the context of other data and information related to the patient. For example, a pharmacist can evaluate a patient and make recommendations drugs and dosage before laboratory results are available that day. Knowing the time of the recommendation allows other members of the healthcare team to accept or reject the recommendation in the context of the data from the most current patients. The contents of the note is organized through a SOAP format (Subjective, Objective, Assessment, Plan) or freestyle format. The format of SOAP is a structured format universally acknowledged, that a freestyle format does not have an accepted organizational structure. The professional writing memo healthcare signed the note at the end of the note. The documents or notes written by students and other participants unlicensed are supported by the licensed professional who is overseeing the unlicensed individual.
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