Spearheading clinical intervention documentation into the future: an Alberta Cancer Board study

Abstract

Objective. The Alberta Cancer Board (ACB) Pharmacy recognizing the significance and merits of intervention documentation examined the reporting methods at the ACB’s two major tertiary cancer treatment centres, the Cross Cancer Institute (CCI) and the Tom Baker Cancer Centre (TBCC). The goal of the project was to identify interventions and actions performed by pharmacists and the resulting outcomes. This information would then be forwarded to the pharmacy computer team to implement electronic documentation of clinical interventions utilizing the pharmacy software program (RxTFC). Data Sources. The student collected information through focus groups, literature reviews, shadowing and interviewing pharmacists, manual/paper documentation review and checking the ‘notes’ section of the computer software program (RxTFC). Study Selection. Published literature on intervention documentation was researched and those relevant to clinical documentation in ambulatory care settings were selected. Data Extraction. There was an extensive data collection process, a student researcher was able to define, identify and develop the types of interventions and actions that ACB pharmacists perform daily and the outcomes of the provision of these clinical services. Mosby’s definitions for intervention, action and outcome were adopted in order to aid when sorting and classifying data collected. Data Synthesis. The types of documentation and a list of interventions and actions are summarized in tables. The results indicate that manual forms that are currently in ACB pharmacies are not being used to their full capacity and/or are not being used as they were originally intended. Possible reasons are a lack of self-reporting, differing reporting styles among pharmacists, a lack of time and/or inconvenient manual documentation systems currently in place. Also, pharmacists differ in their perceptions on what constitutes an intervention. Advantages and disadvantages of both manual and electronic reporting practices are outlined. Conclusions. Clinical intervention documentation is an important tool for pharmacists to ensure that patients are provided with the best pharmaceutical care available in oncology settings. J Oncol Pharm Practice (2001) 7, 35-46