Question:

Must a hospital pharmacist retain documentation for Medicare patients?

Answer:

Even though hospital pharmacists do not receive payment for professional services, legislation may change, so it is better to keep documentation standards high for patient care and to demonstrate participation in patient outcomes. As a general rule, pharmacists should document their findings, assessments, conclusions, recommendations, and counseling in the pharmacy medical record, and the record should follow a standard format such as subjective, objective, assessment, and plan (SOAP). Activities such as verbal orders from a physician, drug-order clarifications, and any adjustments that are made to the initial physician order should be documented as well.

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