Clinical Pharmacy Service Documentation - University of Kentucky

UNIVERSITY OF KENTUCKY HOSPITALPOLICY NUMBER: PH-02-16CHANDLER MEDICAL CENTER FIRST ISSUED: 2/05Department of Pharmacy Policy CURRENT AS OF: 10/10SUBJECT:SEE ALSO:PURPOSE:Clinical Pharmacy Service DocumentationPH-02-01; PH-02-04; PH-02-05To provide pharmacists, pharmacy residents and Pharm.D. students aprocedure for documentation and billing of clinical pharmacy services.A. POLICY: A guideline for documentation of clinical services performed.B. PROCEDURE:1. Clinical pharmacy services shall be documented the patient medicalrecord, written or electronic, (see PH-02-04 for note writing policy) on thedate of service and signed by a pharmacist. Exception: Documentation of“pharmacist communication” is not required in the patient medical record.2. Pharmacists, pharmacy residents and Pharm.D. students must documentclinical pharmacy services in WORx using the appropriate correspondingdocumentation code listed below:a. Pharmacist Medication History Codei. Medical record documentation is required.ii. Outpatient medication regimen and/or investigation of previousadverse drug reactions and medication allergies obtained bycommunication with a patient, caregiver, community pharmacy orphysician/clinic (see PH-02-01 for medication historydocumentation form and policy).b. Discharge Counseling Codei. Medical record and interdisciplinary education form (IEF)documentation is required.ii. Communication with a patient or caregiver regardingthe patient’s medication regimen upon discharge and/orcoordination of discharge medication regimen (i.e. obtainingMedicaid PA for drug).c. Patient Education Codei. Medical record and interdisciplinary education form (IEF)documentation is required.ii. Pharmacist counseling/education provided to the patient relatedto medication regimen and/or disease state.d. Therapeutic Drug Monitoring Codei. Medical record documentation is required.

ii. Any service provided related to monitoring of medicationsincluded in the UKCMC Pharmacy Services ClinicalPharmacokinetics and Anticoagulation Guidelines (please refer toPH-02-05 for pharmacokinetics policy).e. Pharmacotherapy Codei. Medical record documentation is required.ii. Encompasses any service provided and/or communication withthe healthcare team related to a patient’s medication andnutritional therapy (not for medications included in therapeuticdrug monitoring).1. Nutrition consultation2. Dosing recommendations3. IV to PO conversions4. Formulary therapeutic interchanges5. Renal and hepatic dosing adjustments6. Drug interactions7. Any other pharmacotherapy interventionf. Pharmacy Communication Codei. Medical record documentation is not required.ii. Considered any information communicated to otherpharmacy personnel or medical staff.Approved:_______________________ Authorized:____________________________Kimberley Hite, M.S., Pharm.D.John Armitstead, M.S., R.Ph.Associate Director of Pharmacy Services Director of Pharmacy