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SEENA ZIERLER-BROWN, PHARMD.,. FAACP, is Director, Integrated Pharmacotherapy Services, and Associate Professor, Pharmacy Practice, Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL. TIMOTHY R. BROWN, PHARMD., is. Pharmacotherapy Specialist in Family Medicine and Director, Clinical Pharmacotherapy, Center for Family Medicine, Akron General Medical Center, Akron, OH. DAVID CHEN, M.B.A., is Director, Section of Home, Ambulatory, and Chronic Care Practitioners, American Society of Health-System Pharmacists, Bethesda, MD. ROBERT WAYNE BLACKBURN, PHARMD., M.B.A., is President, Health System. Procurement Services, Inc., Laguna Niguel, CA.

Address correspondence to Mr. Chen at the Section of Home, Ambulatory, and Chronic Care Practitioners, American Society of Health-System Pharmacists, 7272 Wisconsin Avenue, Bethesda, MD 20814 (dchen{at}ashp.org).

Purpose. A guide to the appropriate documentation of the critical aspects of the patient medical record to ensure reimbursement and the reduction of medical liability is presented. Summary. Several documentation styles can be adopted to record pharmacist interventions, including unstructured notes, semistructured notes, and systematic notes. Documentation should be clear, concise, legible, nonjudgmental, patient focused, and standardized, and it should ensure patient confidentiality. Systematic documentation styles include SOAP (subjective, objective, assessment, plan), TITRS (title, introduction, text, recommendation, signature), and FARM (findings, assessment, recommendations or resolutions, management). SOAP is the primary form for which payers traditionally reimburse. Systematic documentation should be used to demonstrate how pharmacist interventions improved patient care and should not just be used for reimbursement. Pharmacists have the opportunity to build a collaborative relationship with other professionals and with patients. Documentation can provide evidence of this symbiotic relationship where the pharmacist assists in providing a caring and compassionate environment for the patient’s benefit. Professional liability, as it relates to clinical documentation, can be an issue. Documentation provides the necessary information to successfully manage the process of discovery and the review of the conduct of all parties involved in a liability issue. Conclusion. Documentation in a universal format allows for communication among health care practitioners. Written documentation is one key to a successful, open-communication partnership among providers. In addition, accurate, appropriate, and concise documentation is an essential component of ensuring that the patient care provided is evident, not only for patient safety and continuity but also for cases where reimbursement and quality of care are being challenged contractually or legally. Index terms: Documentation; Interventions; Liability; Medical records; Methodology; Patient care; Patient information; Pharmaceutical care; Pharmaceutical services; Pharmacists; Professional relations; Quality assurance; Reimbursement; Standards