Clinical audit of structured pharmaceutical care plans recorded within a hospital pharmaceutical care service

Abstract

Background Pharmaceutical care as a health care service has already made its mark and been shown to make an important contribution to the health care system. However, there is still a demand from the NHS among others, that pharmacist to a greater extent must document their provision of pharmaceutical care. Tested out in this project, is the application of a Care Issue Categorisation System.

Aims To compare two clinical settings in terms of the profile of pharmaceutical care delivered and the profile of medication use. The findings will be reported in a way which allows quantitative comparison of pharmaceutical care issues addressed by the clinical pharmacy service in a proposed reporting, and a modified categorisation system will be use to accomplish this.

Method A literature review were performed on pharmaceutical care, medicines management, common chronic diseases etc. Process maps were produced to describe the delivery of pharmaceutical care at the General Medical Ward at Glasgow Royal Infirmary. An existing categorisation system was modified and a guideline developed and both used for the analysis of documentation made by the pharmacists. Inter rater agreement on the categorisation system was tested and pharmaceutical activity was compared between two wards.

Result The existing categorisation system was modified in several parts and tested by four investigators. Process maps and analysis of the care issues documented reveal that there was a inconsistency between the pharmacist’s provision of care and documentation. The comparison between two wards showed that the pharmacists had different priorities and documentation.

Conclusion The modified categorisation system is tool that has the potential to aid future documentation of pharmaceutical provision of patient care. Comparison of pharmaceutical care activity between two ward showed that pharmacists are contribution to pharmaceutical care but that there are differences in their priorities and documentation of care issues