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

Abstract

Objective This audit was conducted by reviewing two cohorts of patients in terms of pharmaceutical care delivered by examining free text electronic records and categorising care issues into a proposed reporting system. Qualitative research methods in an action research process were used to test the validity and the utility of the reporting system. A template for an electronic pharmaceutical care plan that meets defined criteria for service developments including non-medical prescribing was proposed by the investigators.

Methods The investigator identified and gathered documented care plans from samples of patients receiving pharmaceutical care during February 2008 to April 2008 using the electronic care monitoring system. The context and outcomes of each care plan were identified by obtaining additional information from paper case records and through dialogue with the clinical pharmacist authors to overcome any gaps in the free text electronic records. An existing categorisation system used at the University of Strathclyde was modified to increase the robustness and clinical usefulness and a guideline for use of the system was developed. A contents analysis of the care plans was conducted in order to categorise the care issues. The inter-rater reliability in the categorisation of the care issues in the survey was demonstrated using Cohens kappa analysis. The proposed care plan template was evaluated in terms of validity and utility for reporting care plans using an action research approach and revised in response to the feedback obtained. The survey findings were also reported to the clinical pharmacy team.

Setting The survey was sited at the orthopaedic ward at the Ayr Hospital where an electronic prescribing system is in use. A clinical pharmacist is at the orthopaedic ward every day from Monday to Friday.

Results Ideas generated from group meeting with the clinical pharmacist at the Ayr Hospital were among others to implement databases and forms that already are used today. The care issue section should be more structured and include functions as review date and predefined texts.

The 90 patients that were included at orthopaedic ward had totally 270 care issues identified compared to the 71 patients at the cardiology ward where totally 377 care issues were identified (p<0.0001). The number of care issues per patient categorised as a Check was significant higher at the cardiology ward than the orthopaedic ward (3.8 versus 1.1, p<0.0001). The subcategory ‘Change in clinical (shared) record of drug history’, which includes changes in the patients drug therapy based on errors or omissions in medicines prescribed on admission, was relative high on both wards (63 issues on orthopaedic and 37 on cardiology). For both wards most of the Checks were done during the treatment of the patient and therefore categorised as a ‘monitoring’. Similarly were the majority of care issues in both of the Change categories found at the ‘verification’ stage in the delivery of the patient’s treatment. Few ‘reviews’ were identified among the ‘Changes in drug therapy’ in both settings. The inter-rater reliability test for the categorisation found the agreement to be highest within the Check and the two Change categories and poorest in the part of the system with the Quality Assurance Descriptors ‘Degree of change’.

Conclusion A care plan template will make the plan more structured and complete and the documentation process more effective and uniform between pharmacists. The categorisation system describes the contribution the clinical pharmacist to the patient’s treatment but there is a need for a language within the pharmaceutical care.