Documentation of Patient Care Services in a Community Pharmacy Setting Kelly A. Brock, Kristin A. Casper, Tara R. Green, and Craig A. Pedersen 378 Journal of the American Pharmacists Association www.japha.org May/June 2006 Vol. 46, No. 3 RESEARCH Received March 31, 2005, and in revised form July 29, 2005. Accepted for publication November 9, 2005. Kelly A. Brock, PharmD, is Assistant Professor of Pharmacy Practice, College of Pharmacy, Western University of Health Sciences, Pomona, California. Kristin A. Casper, PharmD, is Assistant Professor of Clinical Pharmacy, College of Pharmacy, The Ohio State University, and Faculty Coordinator, Kroger Patient Care Center, Columbus, Ohio. Tara R. Green, PharmD, is Clinical Coordinator, Kroger Patient Care Center, Columbus, Ohio. Craig A. Pedersen, PhD, is Associate Professor, College of Pharmacy, The Ohio State University, Columbus, Ohio. Correspondence: Kristin Casper, PharmD, College of Pharmacy, The Ohio State University, A220 Parks Hall, 500 West 12th Avenue, Columbus, OH 43210. Fax: 614- 292-1335. E-mail: casper.17@osu.edu Disclosure: The authors declare no conflicts of interest or financial interests in any product or service men- tioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Previously presented at the American Pharmacists Association Annual Meeting, March 28–April 1, 2003, New Orleans, La. ABSTRACT Objective: To assess the types of patient care documentation systems cur- rently being used by community pharmacists and determine the preferred char- acteristics of an ideal patient care documentation system. Design: Mailed survey. Setting: United States. Participants: One pharmacist from each of 125 targeted community pharmacies. Intervention: Survey mailed in February 2003, followed by a second mail- ing to nonrespondents in March 2003. Main Outcome Measures: Responses to survey items about (1) patient care services provided at the pharmacy, (2) characteristics of the current documen- tation system, and (3) characteristics of an ideal documentation system. Results: A total of 48 usable responses were received from 106 pharmacies to which surveys were delivered (45.3%). Independent pharmacies accounted for 50% of survey respondents. More than 80% of respondents were providing patient screening or management services associated with a chronic disease such as diabetes, hypertension, or dyslipidemia. Approximately 54% of the pharmacists were using a paper documentation system. However, challenges identified with a paper system included documentation time, retrieval of patient data, tracking patient outcomes, and storage. Respondents indicated that an ideal documentation system would be comprehensive, easy and efficient to use, and affordable. Conclusion: Pharmacists recognize the importance of documenting patient care services. While the majority of respondents are using paper charts to doc- ument patient care services, computerized systems appear to offer advantages over paper charts. This information offers community pharmacists a summary of previous experiences and a starting point when trying to identify or modify a documentation system that would better meet the pharmacies’ needs. Keywords: Documentation, medication therapy management services, com- puters, software. J Am Pharm Assoc. 2006;46:378–384.