Documentation of Patient Care

Preceptor Development: Patient Care Process

Outline

• Setting the stage for precepting documentation
• Elements of documentation
• Format
• DAP note
• Content
• Feedback and evaluation of your student
• Overview of the preceptor role
• My practice – an example

​

Setting the Stage

1. Identify and evaluate how you document in your practice
• Review your practice setting with your student
• What are the main reasons for documentation in your practice?
• Where do you document?
2. Get to know your student; specifically, their comfort and experience with documentation.
• How much and what format(s) of documentation have been learned and practiced?

​

​

Setting the Stage

3. Share your approach with your student.
• What format do you use for documenting?
• Pre-printed forms?
• Consultation/free-form note?
• How often do you document?
• When do you document?

​

Elements of Documentation: Format

Essential:

• Date of encounter and time written
• Purpose of note (i.e. Why did you see the patient? Example: Pharmacist Note RE: warfarin education)
• Content: Data, Assessment and Plan
• Pharmacist identifier at end of note (i.e. name, signature, contact number)

​

​

Elements of Documentation: DAP Note

Elements of Documentation: Content

Audience:

• Who is the audience?
• What will they need to know?
• What is their probable attitude about this topic?

Scope

• Keep note focused
• Keep in mind the level of detail required

​

Guide your student about the audience and the scope of the documentation

Feedback and Evaluation

Provide feedback and evaluate your student on the following criteria:

• Appropriateness/scope of information
• Is too much/too little information included?
• Is the note focused?
• Quality of content
• Are the assessment and plan acceptable?
• Are they clearly outlined and conveyed appropriately?

Feedback and Evaluation

• Communication – Clear, Diplomatic, and Timely
• Is the note legible, clear, concise and logical?
• Is the note written in a professional manner without being judgmental or criticizing of others?
• Was it created in a timely fashion?

Note: If student is unable to appropriately document patient care despite feedback and sufficient practice, please contact the course coordinator.

Overview of the Preceptor Role

Early in the clinical placement

• Discuss with your student your expectations regarding documentation of patient care activities
• Review examples of pharmacist documentation in your practice setting
• Review draft documentation notes with your student to identify strengths and areas for improvement, and allow time for editing

Later in the clinical placement

• Promote more independent documentation of patient care as appropriate

​

My practice

• Ambulatory HIV Clinic
• Specialized clinic located within the outpatient medicine clinics at the University of Alberta Hospital
• Patients seen by interdisciplinary team
• Paper-based medical record
• health care professionals document in progress notes section of medical records
• Template (consult letter) developed for more complicated consults

My practice – precepting students

• During orientation, explain:
• What, when, why and how to document

​

• Share examples of pharmacist documentation in chart
• Patient assessment (clinic visits) – adherence, medication history, medication management
• Consultation note- drug resistance, medication intolerances, cardiovascular risk assessment
• Patient education
• Patient Follow-up note
• Other interventions

​

• Draft notes – provide feedback and edit prior to including in chart

​

​