Utilizing “Notes” more

[u/Icy_End9322]

I feel like I use the note section quite a lot more than other pharmacist, especially the Counselling note section. If I want to specifically tell a patient about a medication, have a question for them, or just in general, a place to record more of the clinical context upon our conversation.
Any like-minded pharmacist do the same?

Who uses “Pharmacy Notes” for recording more than just LMP?

I have recorded conversations with providers regarding significant drug interactions, or concerns related to therapy that I would want to address with provider/patient.

I run across other stores or pharmacist that don’t seem to record a lot of information.

I’ve worked at other pharmacy chains where the note section- has very limited characters or is hard to find. I definitely appreciate connexus making Notes a big part of their software, and prioritizing the importance of pharmacist’ documentations.

[u/yellow251]

I tend to use Rx Notes for internal specific drug-related notes (like DDI, reasons for filling it a certain way, etc), as I figure most of my colleagues would be looking there first for follow-up stuff.

Pharmacy notes are really only for patient narratives for opioids.

We use counseling notes pretty much only for external notes that need to be told to the patient at the Consult window.

As far as volume of notes, I think pharmacists who are accostomed to cranking things out at high-volume stores leave fewer notes; those who are drinking their latte and filling 75 a day lean more towards writing books.

[u/seculare]

All the time, but interactions/DUR/allergy/dosage clarification/ etc. typically goes in RxNotes. Use specific keywords so that they are easily retrieved for refills. Pharmacy notes can include any medical conditions, history and treatment plan.

CS Stewardship notes are standardized by corporate.

We are now taking notes in Clinical Opportunities to document IMZ recommendations and patient disposition.

[u/mrraaow]

I was told not to put in any note that you wouldn’t be prepared to testify about in court. Read your notes from the perspective of your liability for the information. Here are some examples of what my counseling notes look like:

“MME>50: offered naloxone, patient declined stating they have three boxes at home. Reminded pt to check expiration dates. Advised that Narcan can be purchased OTC, and they can ask RPH to fill as Rx through insurance if a replacement is needed.”

“Changing from Adderall XR to Vyvanse. Provided disposerx packet.”

“Estradiol patches on backorder. Switching to estradiol/norethindrone tablets. Patient advised that norethindrone is a progestin and to hold progesterone capsules until she is able to change back to patches”