Are you confident in making clinical records?
As the provision of clinical services in community pharmacies continues to grow, pharmacy professionals who want to update their knowledge of best practice in record keeping can access the Centre for Pharmacy Postgraduate Education Documenting in patient clinical records e-learning programme.
This learning programme will support pharmacy professionals to:
- Summarise the legal and regulatory requirements for patient clinical records;
- Describe the information required for clear, concise and appropriate patient clinical records;
- Recognise the required structure expected when writing in patient clinical records; and
- Document details of patient consultations and clinical interventions concisely and accurately in patient clinical records.
Timely provision of clinical records
The requirements within the service specifications for the national community pharmacy clinical services expect pharmacy owners to adhere to defined standards of record keeping, ensuring that pharmacy professionals are making consultation records on the same day of service provision unless exceptional circumstances apply.
Making contemporaneous records at the time of the consultation is the expectation of pharmacy professionals providing services. This not only meets expected professional standards, but it also supports timely provision of data to the patient’s general practice, which will also become available to view by other pharmacy professionals providing a consultation to the patient, should they need to seek further support in due course.
In addition, the IT system suppliers have designed their consultation records to support the provision of the service and clinical decision making, for example, by linking to the Summary Care Record, blood pressure guide, etc. Therefore pharmacy professionals are encouraged to use their IT system during the provision of services to ensure they have access to this clinical decision making support.
