Background After analysing the results and suggestions from a satisfaction survey conducted on internal customers in the pharmacy service (PS), the PS Quality Subcommittee (PSQS) proposed, among other measures, the following improvement action (IA): “Increase the presence of the pharmacist in the computerised medical record (CMR)”.
Purpose Therefore, the objectives of this study were, first, to describe the process undertaken for the implementation of this IA; second, to quantify and analyse participation of the pharmacist in the CMR; and finally, to evaluate its impact.
Material and methods For the first target (phase 1: implementation), the PSQS made a qualitative consensus using a brainstorming technique to establish the schedule of performances (April 2014). For the second objective (phase 2: monitoring and analysis (May–December 2014), we performed a retrospective review of all notes written by pharmacists in the CMR (MambrinoXXI). Finally, (phase 3: evaluation) we measured the degree of acceptance of the pharmacotherapeutic recommendations made from the Unit Dose Drug Distribution System and written in the CMR by pharmacists (September 2014) compared with the previous month (August 2014), in which pharmacotherapeutic recommendations were only sent as a form with the medical order.
Data processing was performed using the computer application Microsoft Office Excel.
Results Phase 1: communication of the proposed IA in a pharmaceutical clinical session. Then, we contacted the computing department, who added a pharmaceutical profile note in the evolution of the patient in the CMR, called ‘pharmaceutical care’.
Phase 2: there were a total of 235 notes from the PS. The fundamental reasons were substitution of not included guide drugs with alternative medications covered by the guide (n = 63), special drug dispensation (n = 31), clarification and/or confirmation of the prescription (n = 23) and sterile/non-sterile compound preparation.
Phase 3: the degree of acceptance was 78.6% vs. 55.94%.
Conclusion The technology allows the medical record to be a tool providing continuous information in a traceable manner, in pharmaceutical care in particular and in welfare in general, throughout the whole process of the patient, helping clinical decision making and thus improving the quality of care.
No conflict of interest.
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