Clinical pharmacy in the hospital environment: focus on the documentation of activities

Abstract

Background: The analysis of the pharmacological therapy, the inter-professional performance and the use of research tools are contributions of the pharmacist in the support of patient and the care team. Documenting care-related professional activities is critical to the continuity of care process. Objective: To check the pharmacist’s perception and practice regarding the documentation of clinical activities. Methods: Cross-sectional study with pharmacists of a hospital in Porto Alegre based on the application of a questionnaire in electronic format with questions related pharmacist’s profile (gender, age, formation), acting in clinical pharmacy (practice) and recording information in the medical record (knowing, practice and importance), between September and October 2016. Descriptive analysis of quantitative data was performed. Qualitative data were analyzed by categorization of central idea and frequency according the discourse of the collective subject. Results: Out of the 27 professionals, who made up a sample, were possible contacts 26.73% of the invited pharmacists participated in the study. A profile of young pharmacists (24 to 35 years old), mostly female (94.74%), with recent college conclusion (01 month to 12 years) and in a private institution (83.16%) was observed. Most of these pharmacists (57.89%) work in more than one sector (internal, satellites and central pharmacies). Conclusions: Pharmacists of this institution recognize the importance and necessity of doing the documentation of their clinical activities. However, not doing this documentation occurs due to practical inexperience, overload of activities, elaboration of institutional policies and the need for training of these professionals.