Treatment Chart Review
To ensure that the medication is appropriate for the patient.
Pharmacists are medication experts and will use their knowledge to help ensure the patient receives appropriate medication and that the medication is safe, effective and economic. Theywill be supported in this role by medicines optimization technicians (MOTs).
1. The pharmacist will review all items prescribed on inpatient drug charts against Trust protocols, policy and guidance, and against national and legal guidance as appropriate, endorsing each medication regardless of whether supplies are requested or not.
2. MOTs will often see a prescription before the pharmacist. If a medicines-related problem is identified, depending on the knowledge and experience of the technician, they will either raise the issue directly with the prescriber, or refer to a pharmacist.
3. A medicines-related problem is defined as ‘an event or situation involving drug treatment that actually or potentially interferes with the patient experiencing an optimal outcome of medical care. Examples of drug-related problems can include:
- Drug selection
- Over or under dosing
- Adherence issues
- Education or information
- Drug interactions
- Side effects
4. Pharmacy staff will engage with the multi-disciplinary team to contribute to the pharmaceutical care of the patient. This is usually in participation at ward rounds, consultation with individual clinical team members, clinical notes review and/or patient
5. Inappropriate, unsafe, ineffective and/or uneconomic medication will be discussed with the relevant member of the healthcare team, usually the prescriber or senior nurse in a timely manner and appropriate alternatives will be recommended if appropriate.
6. Clinical intervention can be defined as ‘Any professional activity by the pharmacy team that improves patient outcomes associated with the use of medicines by recommending a change in the patient’s treatment or means of administration or improves medication
7. Pharmacy staff undertake clinical interventions as part of their professional duty of care and this should be appropriately recorded. These records will be kept by the pharmacist or technician concerned and may be used during clinical supervision.
8. Information that may have a significant impact on patient care is recorded in the patient’s clinical notes.Those interventions considered to have significant impact on patient safety will be logged in.
As part of formulating care plans, response to or lack of response to treatment should be assessed.
9. Pharmacists will use routine biochemistry and pathology test results to monitor and evaluate treatment and adverse effects. Side-effect scales, e.g. GASS, will be used to minimize the impact of side-effects on the patient. When appropriate, monitoring booklets
will be provided for some treatments, e.g. lithium. Particular care will be given to high risk drugs or prescribing strategies, e.g. high dose treatments.
Jed Hewitt, Ray Lyon. CLINICAL PHARMACY SERVICE STANDARDS (Incorporating MEDICINES OPTIMIZATION). 2017.