ORIGINAL RESEARCH

Documentation in the Patient’s Medical

Record by Clinical Pharmacists in a Canadian
University Teaching Hospital
Jean-Philippe Adam, Chloé Trudeau, Charlotte Pelchat-White, Marie-Lou Deschamps,
Philippe Labrosse, Marie-Claude Langevin, and Benoît Crevier

ABSTRACT RÉSUMÉ
Background: In many studies on documentation, the data are self- Contexte : Les données de bon nombre d’études portant sur la tenue
reported, which makes it difficult to know the actual level of documen- des dossiers médicaux sont autodéclarées, ce qui fait qu’il est difficile de
tation by pharmacists in patients’ medical records. The literature assessing savoir exactement dans quelle mesure les pharmaciens consignent les
documentation by clinical pharmacists in health care centres is limited. informations dans les dossiers médicaux des patients. Il n’existe que peu
Objective: To assess the level of documentation in patients’ medical d’études évaluant la tenue des dossiers par les pharmaciens cliniques dans
records by clinical pharmacists at one large urban hospital. les centres de soins de santé.
Methods: This retrospective observational study included all patients who Objectif : Évaluer dans quelle mesure les pharmaciens cliniciens d’un
were followed by a clinical pharmacist during their stay in the Centre important hôpital urbain consignent l’information dans les dossiers
hospitalier de l’Université de Montreal between July 1 and October 31, médicaux des patients.
2016. The primary outcome, the level of documentation in patients’ Méthodes : La présente étude d’observation rétrospective englobait tous
medical records, was categorized as minimal, sufficient, or extensive. The les patients ayant été suivis par un pharmacien clinicien pendant leur
quality of notes and the impact of pharmacy students and residents on séjour au Centre hospitalier de l’Université de Montréal entre le 1er juillet
documentation were evaluated as secondary outcomes. et le 31 octobre 2016. Le principal paramètre d’évaluation, soit le degré
Results: A total of 779 patient charts from 4 inpatient units were included de rigueur des inscriptions dans les dossiers médicaux des patients, entrait
in the analysis. Of these, 563 (72.3%) were considered to have minimal dans l’une des trois catégories suivantes : minimal, suffisant ou exhaustif.
documentation (at least 1 intervention described in writing), 432 (55.5%) La qualité des notes et l’effet de la participation d’étudiants et de résidents
had sufficient documentation (at least 1 note written during the patient’s en pharmacie à la tenue des dossiers ont servi de paramètres d’évaluation
hospitalization), and 81 (10.4%) had extensive documentation secondaires.
(appropriate number of notes in relation to duration of hospitalization). Résultats : L’analyse a porté sur 779 dossiers médicaux de patients
Medication reconciliation performed by pharmacists at the time of provenant de quatre services hospitaliers. Les investigateurs ont considéré
admission was documented in 696 (89.3%) of patients’ records. The que 563 d’entre eux (72,3 %) appartenaient à la catégorie « minimal »
presence of students or residents on a clinical unit was associated with a (au moins une intervention consignée par écrit), 432 (55,5 %) se situaient
significant increase in the percentage of charts with at least 1 follow-up dans la catégorie « suffisant » (au moins une note rédigée au cours de
note (23.6% [120/508] with students/residents versus 12.5% [34/271] l’hospitalisation du patient) et 81 (10,4 %) se rangeaient dans la catégorie
without students/residents; p < 0.001) and the mean number of follow- « exhaustif » (nombre adéquat de notes en fonction à la durée de
up notes (0.59 versus 0.23, respectively; p < 0.001) but had no effect on l’hospitalisation). Les bilans comparatifs des médicaments établis par
other variables. Of a total of 777 notes written by a pharmacist, the overall des pharmaciens au moment de l’admission ont été consignés dans
conformity with pre-established criteria was 56.8% (441/777), and 696 (89,3 %) dossiers médicaux de patients. On a associé la présence
conformity was 43.4% (139/320), 75.1% (272/362), and 31.6% (30/95) d’étudiants ou de résidents dans une unité clinique à une hausse
for admission, follow-up, and discharge notes, respectively. significative du pourcentage de dossiers médicaux affichant au moins une
Conclusions: Documentation by clinical pharmacists in patients’ medical note de suivi (23,6 % [120/508] avec des étudiants / résidents contre
records could be improved to achieve the stated goal of the American 12,5 % [34/271] sans étudiants / résidents; p < 0,001) et du nombre
Society of Health-System Pharmacists and the Canadian Society of moyen de notes de suivi (respectivement 0,59 contre 0,23; p < 0,001),
Hospital Pharmacists, that all significant clinical recommendations or mais leur présence n’a été associée à aucun autre effet sur les autres
interventions should be documented. variables. Le taux de conformité globale aux critères préétablis des

194 CJHP – Vol. 72, No. 3 – May–June 2019 JCPH – Vol. 72, no 3 – mai–juin 2019
Keywords: documentation, pharmaceutical interventions, clinical phar- 777 notes rédigées par un pharmacien était de 56,8 % (441/777) et le taux
macist, patient chart de conformité des notes d’admission, de suivi et de congé était respectivement
de 43,4 % (139/320), 75,1 % (272/362) et 31,6 % (30/95).
Conclusions : La tenue des dossiers médicaux de patients par les pharmaciens
cliniciens devrait s’améliorer pour qu’elle atteigne l’objectif établi par
l’American Society of Health-System Pharmacists et la Société canadienne
des pharmaciens d’hôpitaux, qui veut que toutes les recommandations et
interventions cliniques d’importance soient consignées.
Mots clés : tenue des dossiers, interventions pharmaceutiques, pharmacien
Can J Hosp Pharm. 2019;72(3):194-201 clinicien, dossiers médicaux de patients

INTRODUCTION performed by pharmacists were recorded in patients’ medical

records.12 In the province of Quebec, the Ordre des pharmaciens

O ver the past several decades, the practice of pharmacy has

gradually shifted from drug dispensing to application of the
concepts of clinical pharmacy and pharmaceutical care.1-3 By
du Québec evaluated the practice of health facility pharmacists
since 2011 in relation to its standards of practice.13 This round of
inspection showed a gap in the documentation of information,
assuming patient care duties, pharmacists become responsible
with only 50% of pharmacists documenting sufficiently in
for documenting in the medical record their activities related to patients’ medical records.14 Like the clinical guidelines of the
medication reconciliation, clinical problem-solving, therapeutic Canadian Society of Hospital Pharmacists (CSHP)4 and the
interventions, and patient education.3 The practice of documen- ASHP,5 Quebec’s provincial standards of practice13 state that all
tation has been endorsed by many hospital pharmacist societies significant clinical recommendations and interventions should be
and pharmacy organizations worldwide and is included in documented in the patient’s medical record, according to the
their standards of practice, helping pharmacists to fulfill their pharmacist’s clinical judgment. Many published studies have
professional obligations to ensure continuity of care and to be detailed the clinical activities of hospital pharmacists, but they
fully recognized as part of a multidisciplinary team.4-6 Over time, have provided little information about the level of documentation
clinical pharmacists have used various documentation systems in the patient’s medical record.15,16 In addition, most studies
(such as SOAP [subjective, objective, assessment, plan], TITRS present self-reported data on documentation, which makes it
[title, introduction, text, recommendation, signature], and FARM difficult to know the actual level of documentation by the pharma-
[findings, assessment, recommendations/resolutions, manage- cists, who may be following several patients on a clinical unit.
ment]) to determine what information should be included and Taken together, these results highlight the problem of lack
how it should be communicated in the patient’s medical record.7 of documentation by clinical pharmacists following patients on
However, some studies have shown that pharmacists on inpatient units in the hospital setting. Therefore, the objective of
inpatient units do not routinely complete documentation in this study was to assess the quality and quantity of documentation
patients’ medical records and that documentation varies among about clinical interventions by pharmacists in patients’ medical
countries, hospitals, and clinical departments. Between 2005 and records on 4 inpatient units at the Centre hospitalier de
2012, the American Society of Health-System Pharmacists l’Université de Montréal (CHUM).
(ASHP) conducted 3 surveys, in which 59.0% to 65.0% of re-
spondents reported that their hospitals required pharmacists to METHODS
document drug therapy recommendations and progress notes in
Setting
the patient’s permanent medical record.8-10 In a questionnaire sent
to pharmacists in a 900-bed teaching hospital in London, The CHUM is a tertiary academic centre in Montréal, which
Ontario, 74% (29/39) of respondents reported that they did not moved to a new building, with 772 beds, in November 2017. At
write in the patient’s medical record.11 In a subsequent focus the time of this study, the CHUM was composed of 3 hospitals
group, these pharmacists reported that they recognized the (Notre-Dame, Saint-Luc, and Hôtel Dieu), which together had
importance of documenting relevant issues but preferred to use more than 1500 beds. Pharmacy services are provided 24 h/day,
oral communication or temporary adhesive notes instead.11 with decentralization between the hours of 0800 and 2200.
Similarly, in a cross-sectional descriptive study carried out at the Between 3000 and 3500 medical prescriptions are validated each
Centre hospitalier universitaire Sainte-Justine in Montréal, day. A total of 73 pharmacists (representing 68 full-time equivalents)
Quebec, in 2014 and 2015, only 20% of the interventions contribute actively to teaching during the weekdays. On the

CJHP – Vol. 72, No. 3 – May–June 2019 JCPH – Vol. 72, no 3 – mai–juin 2019 195
 inpatient units, there is no clinical position dedicated to a single respectively) formed a committee to establish detailed criteria
pharmacist; rather each position rotates among 3 or 4 designated defining whether documentation in the patient’s medical record
pharmacists. Each year, the department of pharmacy hosts 35 to was minimal, sufficient, or extensive in relation to clinical practice
40 students and 7 pharmacy residents. These learners contribute standards. “Minimal” documentation was defined as at least
to patient care and are present on the inpatient units for prespeci- 1 written intervention in the patient’s medical record, such as a
fied periods. note in the medical section or a suggestion or verbal order in the
Various methods are used for communication among health prescription section. This composite end point was intended to
care providers, including written notes in the paper medical represent any visible indication of the pharmacist’s activity in the
records during the patient’s hospitalization and electronic charts patient record. “Sufficient” documentation was defined as the
for previous hospitalizations, which are easily accessible to the presence of at least 1 note in the medical section of the patient’s
medical team. Also, pharmacists may use a parallel electronic medical record, regardless of the patient’s length of stay in hospital.
documentation system within the pharmacy software, which is “Extensive” documentation was defined as the presence of at least
accessible only to pharmacy staff. Written information may be 1 admission, follow-up, or discharge note for hospital stays of up
composed of SOAP notes in the medical section of a patient’s to 2 days; an admission note and a discharge note for hospital
record and recommendations or verbal orders from doctors in the stays between 3 and 6 days; or an admission note, a follow-up
prescription section. At the time of the study, the hospital did not note, and a discharge note for hospital stays of 7 days or longer.
have a computerized physician order entry system. No discharge note was expected for any patient who died during
the hospital stay, was transferred to another care unit or health
Study Design facility, or was discharged on a weekend. These criteria were based
This multicentre retrospective study aimed to evaluate the on several studies that have demonstrated the benefits of a
documentation of interventions in patients’ medical records by pharmacist’s medication management during transitions of care,
clinical pharmacists between July 1 and October 31, 2016, in in particular at hospital admission and discharge, on clinical out-
4 inpatient units: hematology–oncology, solid organ transplanta- comes such as medication discrepancies, adverse drug event–
tion, cardiology, and hepatology. Patients who had been followed related hospital revisits, emergency department visits, and/or
by a clinical pharmacist during hospitalization were identified hospital readmissions.17,18
The secondary outcomes included the conformity of notes
with the pharmacy department’s computer software, BDM
with pre-established criteria, the effect of the presence of pharmacy
Pharmacy (BDM IT Solutions Inc, Saskatoon, Saskatchewan).
students and residents on the documentation of interventions,
Patients whose electronic medical records were not available and
and the percentage of suggestions for modification of drug therapy
those who were not followed by a clinical pharmacist were
in the prescription section of the patient’s medical record that
excluded from this study. Four pharmacy students (C.T., C.P.-W.,
were explained and detailed in the medical notes. Medication
M.-L.D., P.L.) collected the data from patients’ medical records
reconciliation electronically entered by the pharmacist into the
held in the electronic clinical information system Oacis (Telus
pharmacy software was also collected.
Health, Montréal, Quebec). The students were divided into pairs,
The criteria for evaluating conformity of documentation
with 10% of all data collected by each pair being double-checked
were inspired by the CSHP guidelines.4 For all types of notes, the
by the other pair. The local independent ethics committee and
heading “pharmacy”, the date and time of the note, and the
independent institutional review board approved retrieval of data
pharmacist’s signature were required. For admission notes, the
from patients’ medical records for the purposes of this study.
pharmacist had to state the reason for consultation and had to
Outcomes mention medication reconciliation, the patient’s allergies and/or
intolerances, the pharmacist’s analysis of pharmacotherapy, and
The primary outcome was the level of documentation in an intervention plan. For follow-up notes, an analysis and a plan
patients’ medical records by clinical pharmacists. A literature were required. For discharge notes, patient counselling and
search of Google Scholar, PubMed, and Embase databases (with discharge medication reconciliation had to be described. To be
the keywords “documentation”, “pharmacist”, “impact”, “practice considered in conformity, a note had to meet all of the criteria for
standards”, “notes”, and “hospital”) and a systematic review of the the particular note type. The number of interventions by
clinical guidelines published by various pharmacy professional and pharmacists documented in the prescription section, consisting
scientific societies (including ASHP, CSHP, and the American of suggestions made by the pharmacist or the pharmacist’s
College of Clinical Pharmacy [ACCP]) yielded no defined criteria transcription of verbal instructions from the medical team, was
for adequate documentation and how to quantify it. collected to understand the involvement of pharmacists in docu-
The authors of the present article (4 pharmacy students and mentation in patients’ medical records, independent of written
3 clinical pharmacists with 4, 6, and 10 years of experience, admission, follow-up, and discharge notes (as described above).

196 CJHP – Vol. 72, No. 3 – May–June 2019 JCPH – Vol. 72, no 3 – mai–juin 2019
Statistical Analysis Table 1. Level of Documentation and Interventions
Included in Patients’ Medical Records
Continuous variables are presented as means (with standard
deviations) or medians (with interquartile ranges [IQRs]), whereas Characteristic No. (%) of
Records* (n = 779)
categorical variables are described as frequencies. The ␹2 test (for Level of documentation†
proportions) and the Mann-Whitney U test (for differences Extensive 81 (10.4)
between means) were used to analyze the distribution of categor- Sufficient 432 (55.5)
ical and continuous variables, respectively, with a significance level Minimal 563 (72.3)
of 0.05. Statistical analysis was carried out with SPSS 24.0 Intervention documented in the prescription section
Verbal orders
software (IBM, Armonk, New York).
Records with ≥ 1 verbal order 142 (18.2)
No. of verbal orders per record 1 (1–2)
RESULTS (median and IQR)
Suggestions
A total of 779 patients followed by a clinical pharmacist at Records with ≥ 1 suggestion 369 (47.4)
the CHUM between July 1 and October 31, 2016, were selected No. of suggestions per record (median and IQR) 1 (1–2)
for this study. One additional patient was excluded because the Verbal orders and/or suggestions
electronic record was not available. The duration of hospitalization Records with ≥ 1 verbal order or 426 (54.7)
suggestion (or both)
was up to 2 days for 112 (14.4%) of the patients, between 3 and IQR = interquartile range.
6 days for 263 (33.8%), and 7 days or more for 404 (51.9%), *Except where indicated otherwise.
with a median of 7 days. The numbers of patients’ medical records †Extensive documentation was defined as presence of ≥ 1 admission,
follow-up, or discharge note for hospital stays ≤ 2 days; an admission
with minimal, sufficient, and extensive documentation were 563 note and a discharge note for hospital stays of 3–6 days; or an admis-
(72.3%), 432 (55.5%) and 81 (10.4%), respectively (Table 1). sion note, a follow-up note, and a discharge note for hospital stays
≥ 7 days. Sufficient documentation was defined as presence of
These results are detailed according to clinical unit in Figure 1. ≥ 1 note in medical section of patient’s medical record, regardless
Medication reconciliation done by pharmacists at the time of of the patient’s length of stay in hospital. Minimal documentation
was defined as ≥ 1 written intervention in patient’s medical record,
admission was documented in 696 (89.3%) of patients’ medical such as a note in the medical section or a suggestion or verbal
records. order in the prescription section.
Among the total of 777 notes written by pharmacists in the
patients’ medical records, the overall conformity in relation to
pre-established criteria was 56.8% (441/777), with conformity pharmacy students or residents on the clinical unit was an increase
being higher for follow-up notes (75.1% [272/362]) than for in the number of patient records with at least 1 follow-up note
admission notes (43.4% [139/320]) and discharge notes (31.6% (23.6% [120/508] with students/residents versus 12.5% [34/271]
[30/95]) (Table 2). The main effect on documentation of having without students/residents; p < 0.001) and the mean number of

Figure 1. Level of documentation in patients’ medical records, by clinical unit.

CJHP – Vol. 72, No. 3 – May–June 2019 JCPH – Vol. 72, no 3 – mai–juin 2019 197
 Table 2. Conformity of Admission, Follow-up, These results are similar to those in a study by Ballandras and
and Discharge Notes* others,12 who reported that 58.4% of patients’ medical records
Characteristic No. (%) of had at least 1 written note from a pharmacist resulting from a
Records pharmaceutical intervention. The wide disparity between the
Admission notes n = 320 proportions of records with extensive and sufficient documentation
Title heading “Pharmacy” 318 (99.4)
may be explained by several factors. For most of the records that
Date and time 236 (73.8)
Pharmacist’s signature 319 (99.7) did not meet the criteria for extensive documentation, the reason
Reason for consultation 305 (95.3) was lack of a discharge note (affecting 85.9% of eligible records
Mention of medication reconciliation 316 (98.8) [578/673]). Given the lack of a definition for “optimal” docu-
Patient’s allergies and/or intolerances 242 (75.6) mentation in pharmacy organizations’ standards of practice, the
Analysis of pharmacotherapy 295 (92.2)
interpretation varies among individual pharmacists, especially in
Plan of intervention 258 (80.6)
Overall conformity 139 (43.4) our context, where 3 or 4 designated clinical pharmacists rotate
Follow-up notes† n = 362 through the same clinical area. For this reason, a committee
Title heading “Pharmacy” 361 (99.7) (consisting of all the authors) developed the criteria for 3 levels of
Date and time 309 (85.4) documentation by consensus. These criteria were based on previous
Pharmacist’s signature 360 (99.4) studies that have demonstrated the benefits of pharmacists’ medi-
Analysis of pharmacotherapy 358 (98.9)
Plan of intervention 315 (87.0) cation management during transitions of care and are compatible
Overall conformity 272 (75.1) with clinical pharmacy practice in North America.17,18
Discharge notes n = 95 The criteria for extensive documentation were based on the
Title heading “Pharmacy” 95 (100) assumption that for a longer hospital length of stay, the pharmacist
Date and time 68 (71.6) would have more time to see the patient and more occasions to
Pharmacist’s signature 94 (98.9)
Discharge medication reconciliation 70 (73.7) document interventions in the patient’s medical records. We
Mention of patient counselling 80 (84.2) believe that efforts should be made to improve these results to
Overall conformity 30 (31.6) achieve the standards of practice established by various pharmacy
*Conformity was assessed in relation to guidelines of the Canadian groups (e.g., ASHP, CSHP, ACCP).
Society of Hospital Pharmacists.4
†A patient’s medical record could have more than 1 follow-up note. The overall conformity of admission, follow-up, and
The n value of 362 refers to the total number of follow-up notes discharge notes with pre-established criteria (based on CSHP
assessed.
guidelines4) was 43.4%, 75.1%, and 31.6%, respectively. In
general, most of the records met most of the criteria, but often a
follow-up notes (0.59 versus 0.23, respectively; p < 0.001) (Table single required element was missing, which meant that the note
3). Although the presence of pharmacy students or residents did not fulfill the criteria for conformity (Table 2). The study also
was associated with a trend toward increased rate of sufficient aimed to evaluate the impact of pharmacy students and residents
documentation (57.7% [293/508] versus 51.3% [139/271]; on the documentation of interventions in patients’ medical
p = 0.09), it did not affect the rates of extensive or minimal records. The involvement of these learners had a significant effect
documentation. The principal topic of intervention in the follow- on the number of records with at least 1 follow-up note (23.6%
up notes was related to safety (44.5% [161/362]), efficacy (20.4% versus 12.5%, p < 0.001) and the mean number of follow-up
[74/362]), dose adjustment (13.8% [50/362]), compliance (5.5% notes (0.59 versus 0.23, p < 0.001), which had a positive effect
[20/362]), drug interactions (3.6% [13/362]), access to medica- on the mean number notes per record (1.13 versus 0.73,
tion (1.4% [5/362]), and other (10.8% [39/362]). When we p < 0.007). These results aligned with those reported in other
analyzed the suggestions and verbal orders that clinical pharmacists studies, which have demonstrated that the educational activities
wrote in the prescription section, we found that suggestions were of students and residents in health care establishments have a
combined with a note in the medical section (64.8% [239/369]) positive influence on patient care.19-21 The presence of pharmacy
more often than were verbal orders (24.6% [35/142]). students and residents did not significantly affect the other
variables. However, this study was not powered to assess a differ-
DISCUSSION ence between the presence and absence of residents and students
To our knowledge, this is the first multicentre study to on the inpatient units. The calculation of a sample size was not
evaluate the level of documentation in patients’ medical records possible because of the absence of data on documentation by
by clinical pharmacists using a method that did not involve pharmacy learners. Taken together, these results suggest that
self-reporting. With regard to the primary outcome, the level of clinical pharmacists cannot actively follow more patients on the
documentation was minimal, sufficient, and extensive in 72.3%, clinical unit, despite the presence of a student, probably because
55.5%, and 10.4% of patients’ medical records, respectively. time must be spent in direct teaching activities.

198 CJHP – Vol. 72, No. 3 – May–June 2019 JCPH – Vol. 72, no 3 – mai–juin 2019
 Table 3. Effect of Students and Residents on Documentation
Category; No. (%) of Records*
Outcome Student or No Students or p Value
Resident Present Residents Present
(n = 508) (n = 271)
Quality of documentation
Extensive 50 (9.8) 31 (11.4) 0.49
Sufficient 293 (57.7) 139 (51.3) 0.09
Minimal 370 (72.8) 193 (71.2) 0.63
Note type
Admission note 215 (42.3) 105 (38.7) 0.36
≥ 1 follow-up note 120 (23.6) 34 (12.5) < 0.001
Mean no. of follow-up 0.59 0.23 < 0.001
notes/PMR
Mean no. of admission, 1.13 0.73 0.007
follow-up, and discharge
notes/PMR
Discharge note† 61/436 (14.0) 34/237 (14.3) 0.91
NS = not significant, PMR = patient’s medical record.
*Except where indicated otherwise.
†In this row, the denominators (total number of patients’ medical records for which a discharge note
was expected) are less than the total number in each category because a discharge note was not expected
if the patient died, was transferred to another care unit or health establishment, or was discharged on a
weekend.

As part of minimal documentation, nearly two-thirds of the hepatology, pharmacists may not have the time to write multiple
suggestions and one-quarter of verbal orders in the prescription notes in patients’ medical records. Clinical pharmacists could
section were detailed or explained elsewhere in the patient’s prioritize their patients, because high-risk patients should benefit
medical records. These results were expected, because the existence the most from their interventions.22,28 To our knowledge, there is
of a verbal order implies that the pharmacist verbally explained little information available on methods to classify high-risk
the intervention to the medical team, and such orders reflect the patients on a clinical unit with already highly demanding
important place of oral communication with the medical team.11 medication needs, such as oncology or solid organ transplantation.
To promote a multidisciplinary approach and to help compre- As described above, pharmacists often document their interventions
hension of their role and interventions, pharmacists should write in the pharmacy software, without recording the information in
a summary of any verbal discussion in the medical section of the patients’ medical records. To increase productivity and enhance
patient’s record.11 In this study, the records of almost 30% of the documentation, pharmacists could print electronic documenta-
patients contained no formal documentation by a pharmacist. tion from the pharmacy software and include it in the patient’s
This result was surprising, because the clinical pharmacists medical record.29,30 Another way to increase efficiency and achieve
completed medication reconciliation at admission for 89.4% better conformity of documentation would be to use preprinted
of patients across the 4 inpatient units. It is possible that some forms.31 Also, improving communication among doctors,
interventions were discussed verbally with the medical team, pharmacists, and unit coordinators could help pharmacists to
without documentation; in addition, the pharmacists may have know when a patient will be discharged. Doing so could help to
chosen to not see some patients because they prioritized other increase the number of discharge notes, thereby increasing the
patients.22 proportion of records with extensive documentation. Finally, as
The overall documentation by pharmacists in patients’ pharmacy practice is continuously changing and improving, it
medical records could be increased. In our centre, all medication will be important to develop educational presentations and
reconciliations are done by pharmacists. With appropriate super- documents to raise pharmacists’ and students’ awareness regarding
vision, pharmacy technician–centred medication reconciliation practice standards for documentation.32
programs have led to effective medication history-taking, This study had both strengths and limitations. Collection of
documentation and communication of data, and enhanced the data by 2 pairs of students may have introduced observation
pharmacotherapy safety.23,24 The clinical tasks of pharmacists in bias. To limit such bias, 10% of all records were double-checked
Canada and the United States have been expanding, which has and corrected, if appropriate, by the other team of students. The
made it more difficult for pharmacists to follow the same number patients’ medical records were handwritten and although the
of patients as in the past.25-27 Because the workload may be too observers were vigilant, some data may have been missed (e.g., if
great in inpatient units with rapid turnover of patients, such as pharmacists did not identify themselves adequately in the record

CJHP – Vol. 72, No. 3 – May–June 2019 JCPH – Vol. 72, no 3 – mai–juin 2019 199
 or if the quality of the handwriting was poor). However, the large 7. Zierler-Brown S, Brown TR, Chen D, Blackburn RW. Clinical documentation
for patient care: models, concepts, and liability considerations for pharmacists.
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have compensated for these limitations. Another limitation was 8. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of
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2006. Am J Health Syst Pharm. 2007;64(5):507-20.
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identify differences among pharmacists, but rather to determine pharmacy practice in hospital settings: monitoring and patient education—
tendencies and trends, in order to ameliorate the practice of a 2009. Am J Health Syst Pharm. 2010;67(7):542-58.
10. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of
group of pharmacists. pharmacy practice in hospital settings: monitoring and patient education—
This study examined an issue that is very poorly investigated 2012. Am J Health Syst Pharm. 2013;70(9):787-803.
and reported in the literature. Comparing the results of this study 11. Pullinger W, Franklin BD. Pharmacists’ documentation in patients’ hospital
health records: issues and educational implications. Int J Pharm Pract. 2010;
with results of similar analyses in other health care centres would 18(2):108-15.
be of interest. We believe that the results of this study can be 12. Ballandras C, Lebel D, Atkinson S et al. Inscription des interventions
pharmaceutiques au dossier de santé des patients. J Pharm Clin. 2016;
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35(1):29-34.
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iinteraction-v6n2/2016112301/ #15 [cited 2018 Oct 30].
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200 CJHP – Vol. 72, No. 3 – May–June 2019 JCPH – Vol. 72, no 3 – mai–juin 2019
30. Zimmerman CR, Smolarek RT, Stevenson JG. A computerized system to Philippe Labrosse, PharmD, was, at time of this study, a pharmacy
improve documentation and reporting of pharmacists’ clinical interventions, student in the Faculty of Pharmacy, Université de Montréal, Montréal,
cost savings, and workload activities. Pharmacotherapy. 1995;15(2):220-7. Quebec. He is now with the Pharmacy Department, CISSS de la
31. Robinson SM, Harrison BD, Lambert MA. Effect of a preprinted form on Montérégie-Centre, Longueil, Quebec.
the management of acute asthma in an accident and emergency department.
Marie-Claude Langevin, BPharm, MSc, is with the Pharmacy Depart-
J Accid Emerg Med. 1996;13(2):93-7.
ment, Centre hospitalier de l’Université de Montréal, Montréal, Quebec.
32. Rector KB, Veverka A, Evans SK. Improving pharmacist documentation of
clinical interventions through focused education. Am J Health Syst Pharm. Benoît Crevier, PharmD, MSc, BCCP, was, at time of this study, with the
2014;71(15):1303-10. Pharmacy Department, Centre hospitalier de l’Université de Montréal,
Montréal, Quebec. He is now with the Pharmacy Department, CISSS de
la Montérégie-Centre, Longueil, Quebec.
Jean-Philippe Adam, BPharm, MSc, BCPS, BCOP, is with the Pharmacy Competing interests: Jean-Philippe Adam has received honoraria and
Department, Centre hospitalier de l’Université de Montréal (CHUM), and consulting fees from Apobiologix, Novartis, Amgen, Abbvie, Janssen,
the Centre de recherche du CHUM, Montréal, Quebec. and Teva, for activities unrelated to the study reported here. No other
competing interests were declared.
Chloé Trudeau, PharmD, MSc, was, at time of this study, a pharmacy
student in the Faculty of Pharmacy, Université de Montréal, Montréal,
Quebec. She is now with the Pharmacy Department, Centre hospitalier
de l’Université de Montréal.
Charlotte Pelchat-White, PharmD, was, at time of this study, a pharmacy
Address correspondence to:
student in the Faculty of Pharmacy, Université de Montréal, Montréal,
Jean-Philippe Adam
Quebec. She is now with the Uniprix Pharmacy Jean-Pierre Bois et François
Centre hospitalier de l’Université de Montréal
Dupuis, Mascouche, Quebec.
1050, rue Sanguinet, porte F08.1109
Marie-Lou Deschamps, PharmD, was, at time of this study, a pharmacy Montréal QC H2X 0C1
student in the Faculty of Pharmacy, Université de Montréal, Montréal,
e-mail: [email protected]
Quebec. She is now with the Pharmacy Department, McGill University
Health Centre, Montréal, Quebec. Funding: None received.

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