Clinical documentation for pharmaceutical opinions
Phase 1 of the Pharmaceutical Opinion Program, implemented April 1, 2011, is best categorized as dispensing or transactional services that positively impact patient care and represent services pharmacists have been routinely providing to patients but without compensation. Most notable are the pharmaceutical opinion as well as services that verify adherence, tolerance and response to medication therapy.
The Ontario Pharmacists’ Association has worked diligently to prepare pharmacists with as much information as possible and we are pleased to introduce a new standardized documentation tool, the Clinical Documentation Form, which will simplify the process for both pharmacists and prescribers.
We have has made every effort to include all of the mandatory documentation elements identified by the Ministry and this form also incorporates feedback from discussions with physicians and nurse practitioner associations who indicated a need for standardized forms which allows them to more easily recognize requests for consultations from pharmacists.
Download the clinical documentation form
Download the clinical documentation form (Customizable for logo)
How to use the clinical documentation form
How to use the clinical documentation form
The Clinical Documentation Form is divided into nine sections. All fields are to be completed by the pharmacist, with the exception of section five which is reserved for the prescriber’s entry (for verbal responses, the pharmacist will transcribe the prescriber’s comments). Please note that pharmacy technicians may only assist in the completion of sections one and two.
- Patient information – This section contains the patient’s full name, date of birth, gender, OHIP number, address and telephone number. Pharmacists can use the “other relevant information” field to include additional information such as a patient’s email address, name of caregiver or agent, etc.
- Prescriber information – This section is for the entry of all of the prescriber’s relevant information including full name, ID number, telephone, facsimile and date/time of transmission to the prescriber. There is also a field to capture the prescriber’s ONE-Mail email address in the event that transmission of this information through Ministry-secured email is enabled.
- Categorization of the drug-related problem (DRP) – The pharmacist will identify the actual/potential DRP and will provide more details as deemed relevant. While optional, it is recommended that the pharmacist indicate the appropriate level of urgency associated with the suspected or real DRP.
- Pharmacist’s recommendation on the identified DRP – This area is reserved for the articulation of the pharmacist’s recommendation to the prescriber. Prescribers have limited time to assess these documents and have therefore requested that any recommendation is clear, complete and concise. There is not a lot of space in this section, and so brevity is important. This section will also record the printed name of the pharmacist initiating the pharmaceutical opinion.
- Prescriber review and comments – This section is reserved for the prescriber to respond to, or comment on, the pharmacist’s recommendation. If the document is being faxed back, the prescriber must authorize his/her response with a signature. If the prescriber calls in his/her response, the pharmacist will transcribe the prescriber’s comments in this field.
- Pharmacist action plan and discussion with patient and comments – This area is for documentation of the pharmacist’s approved action plan and also for the required dialogue with their patient or agent. In the event that the prescriber’s response to the pharmacist in section five was verbal, the pharmacist must check the box indicating receipt of a verbal order. Pharmacists are reminded that an unsigned authorization that does not indicate a “verbal order” is not a legitimate authorization and the claim may be subject to recovery. This section is also reserved for the signature of the pharmacist who will be implementing the action plan. It should be noted that this pharmacist may not be the same individual who initiated the pharmaceutical opinion. Finally, the pharmacist must include their OCP number and indicate the date of the dialogue with the patient/agent.
- Copy of original prescription – The large section in the bottom right quadrant of the form is for affixing the hardcopy of the original prescription or, in the event of a refill, a previously filled prescription label. If the original prescription is larger than the space allows, pharmacists should transcribe the original prescription information in this area.
- Pharmacy use only – At the bottom of the page, there is a mandatory section for the pharmacist to complete. It identifies the outcome of the consultation (as a check box for each PIN option) and is required by the Ministry for inclusion on the record. In addition, this form must be attached or cross-referenced in some manner to the pharmacy hardcopy. A “cross-referenced Rx/Tx number” field has also been included to ensure that this form can be identified with the original prescription hardcopy should the two documents become separated. This is particularly important if there are several drug products listed on the original prescription order from the prescriber and the Rx/Tx numbers are not sequential.
- Blank space – While empty, this section is important as it is reserved for your store information. It provides enough space for a store’s ink stamp and should include the name, address, and telephone and/or fax numbers for the pharmacy.
Once the prescriber has provided his/her response to your opinion, this documentation tool will serve as the new hardcopy if any changes are made.
Download a sample of a completed clinical documentation form.
This form can also be completed on-screen and then printed. The form is not yet integrated with pharmacy software systems and therefore will not interface with the patient’s profile at this time. However, after downloading the form from you can enter your store-specific information in the bottom right corner of the form prior to saving it to your computer system.
- the prescription intervention has occurred
- the patient has been informed
- the prescriber has been contacted
- documentation has been completed and signed by the pharmacist
For all claims, you will need the “PS” intervention code and your Ontario College of Pharmacists (OCP) member number, and the documentation must be cross-referenced to the prescription and include the reason for the pharmaceutical opinion. In the event that the HNS does not recognize your OCP number and OCP designation code “09”, please use the “99999” and “99” codes in the respective fields in your software. The Ministry has assured OPA that changes are being made to the HNS to accommodate the OCP codes.
Phase 1 of the expanded professional pharmacy services also includes pharmacist following up with the patient to determine if there are compliance issues or to confirm that the medication is working. The pharmacist should document these professional services accordingly and the Ministry has indicated pharmacists may bill for both these services. If there are no changes to a patient’s drug therapy as a result of the review, then the no change PIN should be used. If changes are recommended or made to the patient’s therapy, then the PIN indicating that a change was made should be used.
All files pertaining to Phase 1 of the expanded professional pharmacy services must be on the patient’s electronic profile or attached to the prescription hardcopy record. All documentation must be in a readily retrievable format and must be retained at the pharmacy for a minimum of two years.
For additional details about the pharmaceutical opinion program, please refer to the Ministry’s FAQ relating at: http://www.health.gov.on.ca/en/pro/programs/drugs/pharmaopinion/pharmaopinion_faq.aspx.