Clinical audit of pharmaceutical care recorded within a hospital pharmacy electronic prescribing system and the development of a structured pharmaceutical care plan

Abstract

Abstract

Background There is a need for a common way of documenting and planning pharmaceutical care within the electronic prescribing system used at Ayr hospital.

Aims and objectives Conduct a contents analysis of care issues in a formal survey of the care plans in order to categorise the issues, and propose a starting point for an electronic care plan template.

Methods Documentation of pharmaceutical care and the distribution of care issues in two different settings were investigated in a prospective, clinical audit. A categorisation system was modified and guideline for this categorisation system was made, and documented care issues were subsequently subject to content analysis in the system. All results were evaluated in a focus group. A proposal for an electronic care plan template was made

Results It was confirmed in a focus group meeting that the electronic care plan template had captured the needs set by the pharmacists at Ayr Hospital. The validity and usability of the different parts of the categorisation system differed. The content analysis of care issues between two wards at Ayr Hospital showed differences in the mean value of care issues per patient and also the type of care issues most commonly seen at the wards.

Conclusion An electronic care plan template have great potentials. The categorisation system as a whole needs further development, since certain parts of it were ambiguous.