Pharmaceutical Opinion Program — clinical documentation
The Ontario Pharmacists Association has developed a standardized documentation tool to simplify the process for both pharmacists and prescribers.
Clinical documentation form - Word document
How to use the Clinical Documentation Form
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. Pharmacy technicians may only assist in the completion of sections one and two.
- Patient information. Use the “other relevant information” field for additional information such as the patient’s email address, name of caregiver or agent, etc.
- Prescriber information. Note that 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). Identify the actual or potential DRP and provide more details as deemed relevant. It is recommended that you indicate the appropriate level of urgency associated.
- Pharmacist’s recommendation on the identified DRP. Prescribers have limited time to assess these documents and have requested that recommendations are clear, complete, and concise. This section will also record the printed name of the pharmacist initiating the pharmaceutical opinion.
- Prescriber review and comments. Leave this section empty. This area is reserved for the prescriber to respond to, or comment on, the pharmacist’s recommendation. If the document is 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. If the prescriber’s response to the pharmacist in section five was verbal, check the box indicating receipt of a verbal order. An unsigned authorization that does not indicate a “verbal order” is not a legitimate authorization and the claim may be subject to recovery. Note that the signature is required from the pharmacist who will be implementing the action plan, who is not necessarily the one who initiated the pharmaceutical opinion.
- Copy of original prescription. Affix 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, transcribe the original prescription information.
- Pharmacy use only. This section is mandatory. This form must be attached or cross-referenced in some manner to the pharmacy hardcopy. A “cross-referenced Rx/Tx number” field ensures 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. This section 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. You may wish to download the form and enter your store-specific information prior to saving it to your computer system.
Once the prescriber has provided his/her response to your opinion, this documentation tool will serve as the new hard copy if any changes are made.
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.
It is important to remember that a claim for payment can only be made after:
- 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 professional service (“PS”) intervention code and your Ontario College of Pharmacists (OCP) member number. The documentation must be cross-referenced to the prescription and include the reason for the pharmaceutical opinion. In the event that the Health Network System (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.
All files must be on the patient’s electronic profile or attached to the prescription hard copy record. All documentation for the claim must be in a readily retrievable format and must be retained at the pharmacy for a minimum of two years. All patient health records must be in a readily retrievable format and kept on file at the pharmacy for a minimum of 10 years.