CHPPC Module 17, Section 5: Documentation & Communication
Part 5: Data Entry & EHR Mastery

Module 17: Hospital Order Entry Fundamentals

Welcome to the command center of inpatient care. Your experience processing thousands of prescriptions with speed and accuracy is one of your greatest assets. In this module, we will translate that foundational skill into the complex, dynamic world of hospital order entry. We’ll demystify the Electronic Health Record (EHR) and show you that beneath any specific software lies a universal logic—a logic you are already well-equipped to master.

17.5 Documentation & Communication: The Pharmacist’s Permanent Record

Mastering the art of clear, concise, and legally sound communication within the EHR.

If an action or a decision is not documented, it did not happen. This is the cardinal rule of healthcare, and it takes on profound importance in the hospital setting. Every clinical intervention you perform, every clarification you receive from a provider, and every piece of patient education you deliver must be captured in the Electronic Health Record (EHR). This is not administrative busywork; it is a critical component of patient care, risk management, and professional accountability. This final section of the module will teach you how to transform your documentation from a task into a powerful communication tool that enhances patient safety and showcases your clinical value.

Retail Pharmacist Analogy: The Sticky Note vs. The Court Transcript

In your retail pharmacy, when a doctor clarifies a sig, you might jot a quick note—”Per Dr. Smith, ok to do 1-2 tabs”—and staple it to the original hard copy. It’s an informal, internal reminder. Its audience is you and your colleagues. It serves its purpose, but it’s fundamentally ephemeral.

In the hospital, every note you write in the EHR is a formal, permanent, and legal entry into the patient’s medical record. It is not a sticky note; it is a court transcript. It will be read by physicians, nurses, case managers, and potentially lawyers and regulators. Your documentation must be professional, objective, and clear enough for any healthcare professional to understand your thought process and the rationale for your actions, even years later. Mastering this skill is as important as mastering pharmacokinetics.

17.5.1 The Art of the Pharmacist Note: Writing for a Multidisciplinary Audience

Pharmacist notes are your primary tool for communicating non-urgent, yet clinically significant, information to the entire care team. A well-written note can influence prescribing decisions, prevent future errors, and provide a clear record of your cognitive services.

17.5.1.1 Key Principles of Effective Note Writing

  • Be Concise: Providers are busy. Get to the point quickly. Use bullet points or numbered lists for readability. Avoid long, narrative paragraphs.
  • Be Objective: Stick to the facts. Document patient data (labs, vitals), your assessment, and your recommendation. Avoid subjective language or personal opinions (e.g., instead of “The dose is clearly wrong,” write “Patient’s CrCl is 25 mL/min, recommending dose adjustment to…”).
  • Provide a Clear Recommendation: Don’t just identify a problem; offer a clear, actionable solution. State exactly what you are recommending the provider do.
  • “Close the Loop”: Indicate what action you have taken or what the expected next step is. (e.g., “Will monitor morning labs and re-evaluate,” or “Paged Dr. Jones with above recommendation.”).

SOAP Note Format: A Universal Structure

When in doubt, the SOAP format provides a clear, logical structure that is universally understood by healthcare professionals.

  • S (Subjective): What the patient reports (relevant only if you’ve spoken to them). Often omitted in pharmacy notes.
  • O (Objective): The data. Labs, vital signs, medication list, patient’s calculated CrCl, etc.
  • A (Assessment): Your clinical analysis of the data. This is where you state the problem (e.g., “Supratherapeutic vancomycin trough likely due to acute kidney injury.”).
  • P (Plan): Your specific, actionable recommendation (e.g., “Recommend holding next dose of vancomycin and rechecking trough in 24 hours. Will renally adjust dose based on new level.”).

17.5.2 Documenting Provider Clarifications & Callbacks: Your Legal Shield

Verbal orders and clarifications are a common and necessary part of hospital practice, but they are also a high-risk source of error. Your documentation of these conversations is your most important legal and safety protection. It creates a clear, unambiguous record of a provider’s verbal directive.

The “Read-Back and Verify” Mandate

The Joint Commission and other regulatory bodies mandate a “read-back and verify” process for all verbal orders. This is a non-negotiable safety step. After the provider gives you the order, you must read it back to them exactly as you are entering it. They must then verbally confirm that your read-back is correct. Your documentation must explicitly state that this process was completed.

17.5.2.1 Anatomy of an Ironclad Clarification Note

When you document a verbal order or clarification (often as a “telephone order” or a comment on the order itself), it must contain several key pieces of information to be considered complete and legally sound:

  1. Date and Time: The exact time of the conversation.
  2. Provider’s Name: The full name and title of the person you spoke with (e.g., “Dr. Emily Carter, Cardiology Fellow”).
  3. The Exact Clarification: Document the specific change or approval verbatim if possible. (e.g., “Provider approved crushing of metoprolol succinate ER per pharmacy recommendation.”).
  4. Your Name and Title: Identify yourself clearly.
  5. The Magic Words: Your note must conclude with “Read back and verified” or “RBV.” This confirms you followed the mandatory safety process.

Example of a complete note: 10/26/2025 14:30 – Spoke with Dr. John Perry, PGY-2. Clarified that the intended dose for this patient with CrCl 22 mL/min is vancomycin 1g IV Q24H, not Q12H as originally ordered. Verbal order entered. John Smith, PharmD. RBV.

17.5.3 Using Addendums: Modifying vs. Replacing Orders

Sometimes you need to add information to an order without changing its core therapeutic intent. This is where an addendum is useful. An addendum is a pharmacist-initiated modification that adds clarifying information or parameters to an existing order. This is different from discontinuing and re-entering an order, which is necessary when the drug, dose, route, or frequency needs to change.

17.5.3.1 When to Use an Addendum (And When Not To)

Scenario Correct Action Rationale
Provider orders metoprolol but forgets to add “Hold for SBP < 90.” Add Addendum You are adding a standard, protocol-driven safety parameter that does not change the drug or dose. This is a clarification.
Provider orders lisinopril 10mg daily for a patient who is now NPO. Contact Provider to D/C and Reorder The route must change. You cannot change the route via addendum; the provider must issue a new order for an IV alternative.
A nurse calls to say a patient’s IV has infiltrated and they need to switch an IV antibiotic to the PO equivalent. Contact Provider to D/C and Reorder This requires a new order based on an approved IV-to-PO conversion protocol. You cannot simply change the original IV order.
An order for an oral medication is missing the indication. Add Addendum After clarifying with the nurse or provider, you can add the indication (e.g., “for nausea”) as an addendum. This adds necessary information without altering the order’s intent.

Using addendums appropriately streamlines communication and avoids cluttering the patient’s medication list with discontinued and re-entered orders. However, they must never be used to make a substantive change to a provider’s therapeutic order.