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Research Paper

IJPP 2010, 18: 108115 2010 The Authors Journal compilation 2010 Royal Pharmaceutical Society of Great Britain Received May 30, 2009 Accepted January 22, 2010 DOI 10.1211/ijpp/18.02.0006 ISSN 0961-7671

Pharmacists documentation in patients hospital health records: issues and educational implications
Wendy Pullingera and Bryony Dean Franklinb
a

Education and Training, St Georges Healthcare NHS Trust and bCentre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust/The School of Pharmacy, University of London, London, UK

Abstract
Objectives We aimed to identify potential barriers to hospital pharmacists documentation in patients hospital health records, and to explore pharmacists training needs. Our objectives were to identify the methods used by pharmacists to communicate and document patient care issues, to explore pharmacists attitudes towards documentation of patient care issues in health records, to identify and examine the factors influencing whether or not pharmacists document their care in health records and to make recommendations to inform development of a training programme to educate pharmacists regarding documentation in health records. Methods Methods included a questionnaire and focus groups. The study poulation was 40 clinical pharmacists in a 900-bed London teaching hospital. Key findings Thirty-nine pharmacists completed the questionnaire and 32 attended a focus group. Questionnaire responses indicated that 29 (74%) pharmacists did not write in patient health records; most preferred temporary notes. However, most respondents agreed that documenting their input in the health record was important. Few pharmacists believed that writing in health records would affect the doctorpharmacist or patient doctor relationship, or felt that health-record availability or time were barriers. Most knew when, how and which issues to document; however, most wanted more training. Focus-group discussions revealed that pharmacists feared litigation and criticism from doctors when writing in health records. Pharmacists written communication in health records was also influenced by the perceived significance and appropriateness of clinical issues, pharmacists acceptance by doctors, and pharmacists ownership of the health record. Conclusions While recognising the importance of documenting relevant issues in health records, pharmacists rarely did so in practice and preferred to use oral communication or temporary adhesive notes instead. Pharmacists need to overcome their fear of criticism and litigation in order to document more appropriately in health records. A trust policy and training may offer pharmacists a sense of protection, enabling more confident documentation in patients health records. Keywords documentation; health records; hospital; medical records; training needs

Introduction
Communication, whether oral or written, is an essential skill for all healthcare professionals. Ideally, a patients hospital health records should include written communication detailing that patients healthcare journey from admission to discharge. The hospital health record could therefore be expected to include details of the input of all members of the healthcare team regarding patient care. However, it was our anecdotal experience that, in some hospital trusts, pharmacists seldom document their input in these records. Instead, oral communication or the use of temporary adhesive notes appears to be preferred. However, poor documentation of patient care, or indeed complete absence of documentation, may have medico-legal consequences.[13] One report concluded that the loss of a temporary adhesive note contributed to the death of a patient.[1] Although oral communication may be the preferred method for healthcare practitioners in general, written communication may result in more successful outcomes for patients.[1,35] In theory, a documentation system shared among practitioners should enhance collaborative

Correspondence: Ms. Wendy Pullinger, Pharmacy Department, St Georges Hospital, Blackshaw Road, London SW17 0QT, UK. E-mail: wendy.pullinger@ stgeorges.nhs.uk

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communication (i.e. learning from each others perspectives, thought processes and problem-solving skills) and provide a valuable resource for patient care.[6] A literature review revealed that most studies of multidisciplinary hospital health-record documentation did not report any input from pharmacists.[715] The two exceptions reported that pharmacists were allocated a progress note section in the revised multidisciplinary health record, or were part of a steering group reviewing multidisciplinary hospital health records.[16,17] However, in the former study it was unclear whether pharmacists actually used these revised multidisciplinary health records. It is widely accepted that pharmacists should document their patient care activities in some way. However, pharmacists level of documentation has been found to be poor, with lack of formal training a possible contributor.[18,19] Conversely, one study found that, after receiving specific training in health-records documentation, pharmacists demonstrated 100% accuracy in their quality of documentation.[18] Other studies have also described training initiatives to improve pharmacists documentation in health records, but give few details of the training provided.[3,15,16,20] One study found that, following documentation training, some pharmacists still did not document patient care issues; the reasons for this were poorly described.[3] Other studies have explored the issues surrounding documentation and communication after a system of documentation training had been established, rather than before.[10,12,21] In addition to training, researchers have suggested that the quantity and quality of health-record documentation are influenced by a number of other factors. These include individual experience, time, accessibility of records, level of perceived ownership of health records among various disciplines, and style of health-records layout.[717] Previous research into pharmacists documentation in health records has focused mainly on auditing health records and on using questionnaires to explore pharmacists views, generally after a system of multidisciplinary documentation had been introduced. Although such methods reveal the frequency and authorship of health-records entries, they cannot reveal the factors which influence pharmacists practice. Two qualitative, interview-based studies concluded that documentation of care by occupational therapists was a complex issue involving ethical, legal, professional, multidisciplinary and contextual factors.[22,23] The influence of these, and other, factors on pharmacists has not previously been explored. The aims of this study were to identify potential barriers to pharmacists documentation in patients hospital health records, and to explore whether educational strategies may be useful in overcoming these barriers. Our specific objectives were to identify the methods used by pharmacists to communicate and document patient care issues, to explore the attitudes of pharmacists towards documentation in health records, to identify and examine the factors influencing whether or not pharmacists document their care in patients health records and to suggest recommendations to inform the development of an educational training programme for pharmacists regarding documentation in health records.

Methods
The study was conducted in a 900-bed London teaching hospital. The hospital was staffed by 67 pharmacists, of whom 40 had daily ward commitments. Our research population comprised these 40 clinical pharmacists, each of whom would be expected to have the opportunity of documenting their patient care issues in hospital health records. Approval for the study was granted by the local research ethics committee. Two research methods were used. First, a quantitative questionnaire, based on Likert scales, was used to explore pharmacists current methods of, and attitudes towards, communicating and documenting patient care issues.[24] Second, qualitative focus-group discussions were used to explore pharmacists views on these topics in more depth.[25] Both research methods were piloted on two pharmacists (experienced senior clinical pharmacists with previous ward experience) who were thereafter uninvolved.

Recruitment A participant information sheet and consent form was handdelivered to the 40 clinical pharmacists during May 2005. Participants were contacted a week later and any questions answered. The first author (WP) then collected signed consent forms 2 weeks later. Questionnaire A 20-item Likert scale self-completion questionnaire was developed to determine whether or not pharmacists reported documenting their patient care issues in the hospital health records, and the reasons for and influences on their practice. Questions were informed by the personal experience of the first author (WP), discussion with non-participants (the same experienced senior clinical pharmacists with previous ward experience) and the existing literature. Likert scales had five points, comprising the options strongly agree, agree, neither agree nor disagree, disagree and strongly disagree. The questionnaires were anonymous but coded.[24] A comments section was included at the end of the questionnaire to enable participants to express further opinions. Comment responses were analysed using grounded theory and combined with the focus-group analysis.[26] The questionnaire was sent to all the pharmacists who consented to take part in the study. Focus groups A written invitation to join a focus group was delivered to consenting participants in August 2005; participants were given a choice of several dates. Focus-group dates were allocated to participants, with the aims of attaining group sizes of six to 10 participants, and of avoiding grouping line managers together with their staff. We also aimed to mix within each group participants who reported writing in health records and those who preferred not to (according to questionnaire responses). Focus-group allocation was managed by coded questionnaire returns. Four separate focus groups were held. Topics of discussion were based on the

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questionnaire responses with the aim of exploring and clarifying areas of ambiguity highlighted in the questionnaire. The meetings were held during lunchtimes in the pharmacy department. Refreshments were provided. Seating was arranged in an oval shape, to accommodate a recording microphone on the side opposite the researcher. Focus-group discussions were audio-recorded by a non-participant senior pharmacist with no clinical ward commitments (nor managerial connection to participants). A participants guide to the focus group included ground rules. The first researcher facilitated the discussion. Recordings of each focus-group discussion were transcribed and the transcripts analysed using grounded theory. Data were subjected to open coding, followed by axial and then selective coding.[26] Coding was checked by the second author.

The responses suggested that most pharmacists did not write in the health record as a matter of course, and that most felt that the health records did not include all the information regarding their pharmaceutical care. Although most agreed it was important to have permanent documentation of pharmacists healthcare input in health records, they tended to write on temporary adhesive notes rather than in the actual health record itself. Opinion was divided as to whether these temporary adhesive notes were more visible and less timeconsuming to write than documentation in the health record. Most pharmacists felt that they knew when, how and which pharmaceutical care issues to document in the health records; even so, most pharmacists wanted to receive further training in this process.

Results
Questionnaire All 40 pharmacists approached to complete a questionnaire agreed to do so. Of the 40 questionnaires distributed, 39 were returned; the remaining pharmacist had subsequently transferred to a non-clinical area. Respondents had been qualified for a median of 5 years (range 118 years). When asked how often they currently wrote in health records, respondents reported a range of 0.5 entries per month to two entries per year. None of the pharmacists were prescribers; 28% were specialist pharmacists. Table 1 summarises the responses to the questionnaire statements.
Table 1 Summary of questionnaire responses Statement

Focus groups Following analysis of the questionnaire results, the focusgroup discussion was based around the following questions. First, what were the general issues and personal issues which influenced pharmacists when documenting patient care issues in the health records? Second, the questionnaire results indicated a discrepancy: most pharmacists (66%) either disagreed or strongly disagreed that the health record contained all the information regarding the patients pharmaceutical care. Despite this, 79% agreed that it was important to have a permanent record of their input in the patients health records. Why had this discrepancy occurred, and what was its significance?

Score Median 1st quartile 3rd quartile

Positive 1 The patients health record contains all the information regarding their pharmaceutical care 4 My written contributions in patients health records are acted upon by the doctor 5 I write my pharmaceutical care issues in the patients health record 10 It is important to have a permanent record of pharmacists input to patient care in the health record 12 I know when to write pharmaceutical care issues in health records 13 I know which pharmaceutical care issues to write in health records 14 I know how to write pharmaceutical care issues in health records 18 I would like to receive training in writing pharmaceutical care issues in health records 19 I write in health records as a reminder to the doctor about pharmaceutical care issues 20 I write my pharmaceutical care issues in the health record as a matter of routine Negative 2 I write my pharmaceutical care issues on Post-it or pre-printed pharmacy notes rather than in the patients health record 3 I write on Post-it or pre-printed pharmacy notes because this is more visible than writing in the health record 6 I am concerned that writing in the patients health record could affect my relationship with the doctor 7 I write in health records as a last resort 8 I write on Post-it or pre-printed pharmacy notes as a reminder to the doctor about pharmaceutical care issues 9 I am concerned that writing in the patients health record could affect the doctorpatient relationship 11 I find it less time-consuming to write on Post-it or pre-printed pharmacy notes than in the health record 15 Post-it or pre-printed pharmacy notes are filed as a permanent record of pharmaceutical care in the patients health record 16 I do not have enough time to write in the health record 17 I write on Post-it or pre-printed pharmacy notes because the health record is often not available

2 3 2 4 4 4 4 4 3 2 2 3 4 3 2 4 3 4 4 4

2 3 2 4 3.5 3 3 3.5 2 1 1.5 2 4 2 1.5 4 2 4 2.5 3.5

3 4 3 5 4 4 4 4 4 2 3 4 4 4 2 5 3 5 4 4

Positive statements were coded from 5 (strongly agree) to 1 (strongly disagree) and negative statements from 5 (strongly disagree) to 1 (strongly agree).

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Third, the questionnaire results also indicated a further apparent contradiction: most pharmacists (70%) knew which pharmaceutical care issues should be written in the health records, when to write them and how they should be written, yet most pharmacists (74%) still wanted to receive further training. What accounted for this contradiction? Of the 39 questionnaire respondents, 32 (82%) attended one of the four focus groups. Of the seven non-attendees, three had left the hospital, one forgot, two did not attend for unknown reasons and one did not attend due to the first researchers administrative error. Participants in the first group were fairly junior in experience; those in the second were more senior. The third group had at least one participant from each seniority grade, and the fourth group comprised mainly middle-grade participants. The themes arising from the focus-group discussions were grouped into seven main areas: communication strategies, fear of litigation, fear of criticism, team acceptance, ownership of the health record, and appropriateness and significance of issues. Figure 1 shows how these areas are inter-related.

whatever that would be, either ringing the registrar or leaving a note in the medical notes. (focus group 1, Q14) It seems a much bigger thing to write in the notes rather that a little note on aon the front of the drug chart; it seems a much more formal, perhaps challenging issue when you write in the notes. (focus group 4, Q26) Participants reported using oral communication most often. Temporary adhesive notes were used for minor or housekeeping issues. Health-record documentation was reportedly used for important issues and patient safety concerns, and when the doctor appeared to have ignored the pharmacists oral and/or temporary adhesive note communication. Participants discussed communication duplication and format escalation, and reported sometimes using documentation in the health record (which was perceived as daunting) as a last resort.

Communication strategy Pharmacists choice of communication method depended on the context of the situation. The communication format selected (i.e. oral, temporary adhesive notes or permanent health-record documentation) depended on the perceived level of significance of the issue and the perceived appropriateness of the format selected (note: in the following, Q indicates participant number). I think if its important Id speak to the doctor; if its not important then I leave a sticky note, in which case its probably not important enough to go into the notes. (focus group 3, Q31) Once youve spoken to a house officer or maybe [senior house officer] and, um, have written a note and are still being ignored, and then youd just like to take the next step,
Perception of ownership of the medical notes

Fear of criticism Perception of appropriateness of the issue Communication strategy Fear of litigation Perception of acceptance by others

Perception of significance of the issue

Figure 1 Issues influencing pharmacists communication strategies

Fear of litigation Writing in the health record was done reluctantly and often as a last resort. Fear of litigation was both a reason for and against health-record documentation. You wouldnt want to be wrong in the notes, as well. I feel like thats a factor; youve got to be pretty sure of your facts; itd be really embarrassing if you wrote something ridiculous in the notes, and thats definitely a factor. (focus group 3, Q21) It can take years to get the experience about deciding whats appropriate and whats inappropriate, and if you make the wrong mistake early on it could put you off doing it forever. (focus group 1, Q34) We need to have some kind of formal agreement, you know, formal policy supporting everyone so that the people who havent got the confidence and dont feel they can do it, do it. (focus group 1, Q34) If theres no policy and no guidance and you do somethingyou dont feel covered at all. (focus group 1, Q14) Write it in the notes when you see something that you want to cover yourself, so youdo it as a matter of defence, you dont do it as a routine. (focus group 3, Q6) Ive documented for things like drugs in pregnancy and breastfeeding, where you could have implications later on if something happened to the patient, sorather than just a verbal thing, just so we know thatwell, its written down that weve given the correct advice, soif they dont take that advice then we dont get the blame in pharmacy. (focus group 4, Q37) Pharmacists perceived that a high degree of accuracy, knowledge and experience was needed for health-record documentation. However, self-protection encouraged participation in health-record documentation. Lack of training and lack of authorising policies regarding pharmacist healthrecord documentation were perceived to indicate lack of protection for the pharmacist, which discouraged healthrecord documentation. Pharmacists perceived that in certain clinical areas such as paediatrics, health-record documentation was more often used due to the potential for litigation. Pharmacists wanted training and a formal hospital policy which authorised and supported them in medical-record

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documentation; both initiatives were perceived to offer protection to pharmacists, particularly if things went wrong.

Fear of criticism As well as fear of litigation, focus-group participants also revealed their fear of criticism from doctors regarding any health-record documentation. This fear appeared to relate both to the content of documentation and also to the actual act of writing. If you do something thats relatively inappropriate in care of the patient, or [are] critical of the team or a decision or something, thats there permanently in the medical record. (focus group 1, Q34) See, Ive seen doctors criticise other doctors and professionals for things that have been written in the notes. I definitely do consider what they would think of what Im writing, before I would do it. (focus group 1, Q34) A lot of pharmacists are scared of writing in medical notes, cos, you know, someone might come back to them if its written in the medical notes but they wont come back to them if its written in the drug chart. (focus group 2, Q25) I think its definitely a confidence thing though, cos were very apologetic and we encourage doctors as well, like sorry to bother you but. Its the same as in the notes, isnt it? The confidencelike, am Iwhat Im saying is right? And I dont want to have it written in paper if they think its wrong. (focus group 4, Q35) And everyone can read it, exactly, and your opinion isnt necessarily seen to be as valid as a physicians opinion is. (focus group 4, Q20) To be more assertive. I think were quiteas pharmacists, as a group of people were quiteI dont knowwe stand back. Were not always the first person to come in with a new, kind of, suggestion, idea or whatever; we need to, kind of, believe in what we say more often as well. (focus group 3, Q38) Team acceptance Fear of criticism appeared to be less of an issue if the pharmacist felt accepted as part of the multidisciplinary team, although this relationship did not necessarily encourage health-record documentation. Oral communication appeared to engender less fear of doctors criticism than written documentation. Such two-way communication allowed practitioners to share their opinions about an issue more freely, and was felt to be a less contentious approach. But equally if youre that involved in the patients care and youre attending that ward round you might not have the need to write in the notes cos youve got a very good rapport with your team; you wont need to, you know, makewrite those things down; you can discuss them on a one-to-one basis. (focus group 1, Q3) Ownership of health record Pharmacists reluctance to document in the hospital health records was also influenced by their limited sense of ownership of the health record. Its difficult to compare to dieticians because [the] nature of their work is, you know, nutritional feeding of a patient, and a doctors never going to really contest the feeding of a

patient on the whole, whereas ourour interaction with the doctorspotentially theres room for more conflict. (focus group 1, Q34) I think that those disciplinesthose people, umit actually determined whether the patient can go home or not, whereas what pharmacists tend to write doesnt really its more just, oh, improvement or clarity in drug management, whereas the patient must be able to climb stairs. (focus group 2, Q22) The one thing we dont do at the minute is that we dont actually correct notes, even when we know that theres something wrong in there, like, for example, drug history inon clerking its wrong, and were not correcting. (focus group 2, Q32) Ill see them walking round and then Ill see they havent done anything, so Ill grab the chart and put [it] in their face and say did you read my note? oh, no, I saw something but I didnt read it. But whenever IIve only written in the notes a few times, and because I think its in the notes and they know they have to be accountable for it, theyve acted on it. (focus group 3, Q16) Physio[therapist]s and [occupational therapists] have probably been much more involved physically with the patient care at ward level; were maybe relative newcomers and havent established. Maybe its a cultural thing in each individual hospital; if youve worked in a hospital at an early stage where you were encouraged to do that, and I certainly wasnt. (focus group 1, Q34) But as pharmacists we have a culture that we dont really write in the notes and so its a really big issue when we do write in the notes. (focus group 4, Q26) I think we are really wrapped up in supply, andand TTAs and discharges, and I think that therefore we often dont make the time, or dont have the time, to sit down and document in the notes. (focus group 3, Q21) But [health-record documentation is] recognised as part of [the doctors] job and therefore theyre staffed in such a way to assume that thats part of their job. (focus group 2, Q18) Although other non-medical healthcare practitioners routinely documented in the health record, pharmacists perceived that these practitioners areas of clinical expertise were not interchangeable with those of any other healthcare professional. Such a specialist healthcare practitioner was therefore less likely to be challenged by others. Some pharmacists felt their skills were interchangeable with those of doctors, and that their written contributions were thus more vulnerable to challenge. Pharmacists appeared to feel much more ownership of medication charts and communication with temporary adhesive notes, and felt safer using these modes of communication. However, pharmacists were unclear whether doctors were aware of pharmacists communication via temporary adhesive notes and, even when the doctors were aware, whether they acted on or ignored such communication. A sense of ownership of the medical record was also influenced by traditional and cultural viewpoints. Practitioners tended to write in the health records where this practice was expected and accepted. Pharmacists felt that their perceived traditional roles generally discouraged them from medical-record documentation.

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Pharmacists also felt that, as their allocated time on the ward was limited, it would be unrealistic to routinely document all pharmaceutical care issues in every patients medical record. Other healthcare disciplines were perceived to be better staffed and therefore more able to support a documentation culture.

Appropriateness and significance of issues Pharmacists perceived that only significant and appropriate issues should be written in the health record. A lot of the interventions we make are very minor, and I dont think thats appropriate to put in the notes because youd end up with reams of pharmacy waffle, and its a legal document at the end of the day, and, um, I dont think it would look very good on us if we put in, kind of, every timeevery minor. (focus group 4, Q37) Junior pharmacists, where some would feel apprehensive, whereas others may not, and be putting information which would be inappropriate. So, in a way, youve got to set some standards, which will be a form of training. (focus group 2, Q22) I discussed it with the [senior house officer] you know the team, um, and also wrote it down in the medical notes cos I felt it was quite a complex interaction quite a complex query. (focus group 2, Q18)

Discussion
This study found that, in general, pharmacists reportedly did not write their pharmaceutical care issues in the hospital health records. Their decision regarding whether or not to document in the health records was influenced by fear of litigation, fear of doctors criticism, the perceived significance and appropriateness of the issue to be documented, team acceptance of the pharmacist and perceived ownership of the health record.

Limitations Focus-group participants responses may have been influenced by the previously self-completed questionnaire. Due to the small time delay between successive focus groups, participants may have shared information with those yet to attend. Since focus groups were held during lunchtimes, they had a maximum duration of 1 h, which may have reduced the opportunity for further discussion. The presence of the researcher could have resulted in bias, with participants volunteering responses they thought the researcher would like to hear. Different levels of seniority within the same focus group may have intimidated junior participants. The study took place in one hospital; we do not know how generalisable the findings may be to other sites. Implications of results This study raises many issues. Of foremost concern is the issue of where pharmacists document their pharmaceutical care, if they do not do so in the hospital health record. Pharmacists in this study preferred to document their pharmaceutical care issues on medication charts or on temporary adhesive notes. However, it was recognised that information communicated in both these forms was at risk of being lost or overlooked, with

resulting risk to the patient. In some clinical specialties (e.g. paediatrics), heightened concern over the implications of lost clinical information resulted in more thorough documentation practices. It would thus appear that better documentation was encouraged by the more emotive and perhaps more litigious nature of certain clinical specialties. Doctors poor documentation in medical records is a wellreported problem.[27,28] The implications of this are farreaching. It was possible that pharmacists felt the need to collude with what they perceived as a medical self-protection system. Such collusion could take the form of communication via discussion rather than health-record documentation; this would both protect the doctors and avoid their criticism. Pharmacists selected communication systems based on the perceived appropriateness and significance of the issues involved. Insignificant issues were thought inappropriate for medical-record documentation. Significant issues were considered appropriate, but only under certain circumstances; for example, when patient safety was compromised or when initial verbal or temporary-adhesive-note-based communication had failed. In such a situation, writing in the health records represented a last resort that was linked to the need for self-protection and the necessity to appeal to other members of the medical team. Health-record documentation was not perceived to be standard practice by pharmacists, and was seen by many as tantamount to intruding on doctors territory. As healthrecord documentation was unusual for pharmacists, they perceived that doctors would take more notice of and be more accountable for pharmaceutical issues documented in this way. The focus groups revealed that the pharmacists sense of health-records ownership was so poor that mistakes they discovered in previous medication histories were sometimes left uncorrected. The resulting medication errors could have been prevented by more assertive practice. The pharmacists studied were clearly afraid of criticism, and felt the need to be deferential and polite when writing in medical records. A very small number of pharmacists appeared to regularly write in medical records. This situation may have arisen due to the specialist nature of these practitioners work, which made documentation of their unique input an accepted and expected practice. This belief was also revealed by the fact that pharmacists felt more confident in documenting specific clinical issues (e.g. therapeutic drug monitoring or renal medication dose calculation) in which they had unique expertise and were thus less vulnerable to challenge. A formal hospital policy and relevant training were perceived as offering protection which would relieve pharmacists fear of criticism and litigation and improve their perceived ownership of the medical record.

Comparison with previous literature Some of the issues (such as perceptions about ownership of records) raised in this study have not been explored elsewhere. However, our results do support the findings of other studies which encountered similar problems in developing multidisciplinary patient record documentation.[717] These studies revealed an over-reliance on oral communication, lack of health-record ownership and a perceived poor acceptance by

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doctors of health-record documentation by other healthcare practitioners. Other problems included lack of available time, limited experience, record inaccessibility, adverse culture, and inadequate or non-existent implementation of existing documentation policies.

pharmacist health-record documentation will not evolve unless traditional structures of practice are changed.

Declarations
Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Acknowledgments This study was completed in part fulfilment of a Masters in Education degree (Leeds University, UK). We thank Jan Poloniecki for statistical advice, Chikondi Savieli for focusgroup assistance, all St Georges pharmacy staff for their patience and generous support, especially those who participated in the study, and Lisa Colledge for copy-editing assistance. The Centre for Medication Safety and Service Quality is affiliated with the Centre for Patient Safety and Service Quality at Imperial College Healthcare NHS Trust which is funded by the National Institute of Health Research.

Future studies Further exploration of similar issues in other hospitals would be invaluable to determine the extent to which our findings are generalisable elsewhere, and to investigate whether, and why, different cultures exist in different organisations regarding pharmacists health-record documentation. Further research is needed to explore doctors perceptions of pharmacists (and other practitioners) health-record documentation. Finally, research is needed to explore the impact of pharmacists health-record documentation on patient care. Education issues and implications The pharmacists in this study believed that receiving training in health-record documentation would give them the confidence to write in the health records. These pharmacists also believed that an appropriate training programme, including assessment in health-documentation skills, would ensure the quality and competency of their health-record documentation. Guidelines on health-record documentation should be developed to aid confidence. An interactive and collaborative training programme, using the guidelines, could include specific scenarios of when, what and how to write in health records. Junior pharmacists could also be asked to produce draft health-record entries for discussion with a tutor. However, if in practice health-record documentation occurs within a milieu of fear of litigation and doctors criticism, developing positive practice becomes a more complex challenge for the clinical educator. Any effective training programme would need to address the challenges of confidence-building, assertiveness and management of criticism. A simple change in practice may be the most appropriate first step in changing pharmacists attitudes and beliefs, for example recording a patients medication history in the hospital health record instead of the medication chart, or correcting inaccurate medication histories encountered in the health record. Such changes may begin to enable pharmacists to write in patients hospital health records with more confidence.

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Conclusions
In this study, pharmacists preferred to use oral communication or temporary adhesive notes rather than routinely record patient care issues in patients health records. A variety of reasons were identified. One could speculate that if healthrecord documentation was taught to pharmacists at undergraduate level, this may go some way to preventing the development of disabling attitudes and beliefs. Postgraduate training programmes must acknowledge and defuse learned attitudes and beliefs that impede effective health-record documentation. Involving other practitioners in training programmes (e.g. doctors, occupational therapists and dieticians) may alleviate pharmacists fears and misconceptions. However, regardless of training initiatives, effective

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