Rx Note

Introduction Medical/case note entries are legal documentation of all contributions made by healthcare providers in a patient's care. It facilitates effective communication among healthcare providers by enabling the sharing of concise, informative and auditable records. Therefore, it is essential for a pharmacist to make proper medical/case note entries (if applicable). Medical Documentation Clinical note entries shall be non-judgemental, provide accurate information and practical recommendations regarding patient care and be politely written. Notes shall be limited to information related to the assessment or recommended plan only. Entry by pharmacist into the clinical case note Start by writing the date and time on the top, left-hand corner of the note (for paper or non-form notes). Write a header that indicates the note is from the pharmacy . At the start of a note, identify patient's age and gender, the reason for interaction with the patient and the condition(s) for wh...