CHPPC Module 29, Section 29.1: Note Types & When to Use Them
MODULE 29: DOCUMENTATION MASTERY

Section 29.1: Note Types & When to Use Them

Mastering the Three Essential Tools of Pharmacist Communication: Clarifications, Recommendations, and Education.

SECTION 29.1

Note Types & When to Use Them

Choosing the right communication tool for the right clinical moment.

29.1.1 The Pharmacist’s Voice: From Spoken Counsel to Written Record

In your community practice, your voice is your primary instrument. You use it to counsel a nervous parent about their child’s first antibiotic, to persuade a patient of the importance of statin adherence, and to collaborate with a prescriber’s office over the phone. Your words, though often fleeting, have immediate and profound impact. This verbal dexterity is a core competency you have spent years perfecting.

As you transition into the hospital, the nature of your voice fundamentally changes. While direct verbal communication remains vital, a new and arguably more powerful instrument is placed in your hands: the written note in the Electronic Health Record (EHR). Every character you type into that box becomes a permanent, legally binding, and widely disseminated part of the patient’s story. It is your voice, amplified and recorded for every member of the healthcare team—physicians, nurses, specialists, case managers, and future care providers—to see.

This shift from a primarily spoken to a heavily written mode of communication is one of the most significant adjustments you will make. A poorly written note can be ignored, misunderstood, or even create confusion. Conversely, a well-crafted note is a precision tool. It can prevent a catastrophic medication error, catalyze a life-saving change in therapy, showcase your clinical value, and protect you and the institution from liability. Mastering the art of documentation is not an administrative chore; it is the mastery of your professional voice in its most enduring form.

This section is dedicated to the three fundamental types of notes that will form the backbone of your written communication. Think of them as the three primary modes of your new voice:

  • The Clarification Note: Your voice as the guardian of safety, seeking to resolve ambiguity.
  • The Recommendation Note: Your voice as the clinical expert, proposing a better therapeutic path.
  • The Education Note: Your voice as the teacher, empowering patients and colleagues with knowledge.

Understanding the distinct purpose of each note type, knowing precisely when to use it, and mastering the language required for each is the first and most critical step in becoming an effective and influential hospital pharmacist.

29.1.2 The Clarification Note: The Foundation of Safety

The clarification note is the bedrock of your documentation practice. It is your most frequently used tool and the one most directly tied to the prevention of immediate harm. Its singular purpose is to resolve ambiguity and eliminate uncertainty from the medication use process. In the complex, fast-paced hospital environment, ambiguity is the direct precursor to error. An order that is vague, incomplete, or contradictory is not just an inconvenience; it is an active threat to patient safety.

Your experience in retail pharmacy has already made you an expert in identifying these ambiguities. Every time you received a prescription for “Lisinopril #30” with no strength, or a sig that read “take as directed,” your professional instincts compelled you to pick up the phone. You refused to guess. You sought clarity. The hospital-based clarification note is the formal, documented version of that phone call. It codifies your due diligence and creates a permanent record of the identified issue and its resolution.

The Golden Rule of Clarification

If you have to ask yourself “I wonder what they meant by that?”—you need to clarify. Never assume intent. The gap between a prescriber’s intent and what is written in an order is where medication errors are born. Your job is to stand in that gap and close it with clear, documented communication.

The process of clarification is not merely about finding a missing piece of information. It’s a systematic investigation. Before you even begin to write your note or make a call, you must perform a rapid but thorough data-gathering exercise. You must become a micro-detective, using the EHR to find clues that might resolve the ambiguity without needing to contact the prescriber, or at a minimum, arm you with all the necessary context to make your inquiry efficient and intelligent.

Masterclass Table: Common Triggers for Clarification & The Pharmacist’s Workflow

The following table outlines common scenarios that must trigger a clarification. It details the parallel you’re already familiar with from retail, the potential risk, the investigative steps to take before communicating, and examples of ineffective vs. effective documentation.

Trigger for Clarification Retail Pharmacy Parallel The Specific Risk & Hospital Example Pharmacist’s Investigative Workflow (Before Writing) Example Note Structures (Ineffective vs. Effective)
1. Ambiguous or Missing Frequency An Rx for “amoxicillin” with no frequency, or a sig of “take as needed for pain.” Risk: Over- or under-dosing, potential toxicity, or therapeutic failure.
Example: An order for “Furosemide 40mg IV” is entered. Is this a one-time dose? BID? TID? The nurse cannot safely administer this order.
  1. Review recent orders: Was this medication ordered previously with a frequency? Is this a re-order where the frequency was accidentally omitted?
  2. Check provider notes: Does the H&P or Progress Note mention a specific dosing plan (e.g., “will diurese with IV Lasix 40mg BID”)?
  3. Review MAR: How was this medication given previously during this admission or a prior one?
  4. Assess clinical context: Is the patient fluid overloaded, suggesting a scheduled dose is needed? Or was it for a transient issue?

Ineffective: “Order missing frequency.”

Effective: “Clarification needed for furosemide 40mg IV order which is missing a frequency. Patient’s morning weight is up 3kg from admission, and progress note mentions plan for diuresis. Please clarify intended frequency (e.g., BID, TID) or if this was intended as a one-time dose. Will pend order awaiting clarification.”
2. Missing or Unclear Route of Administration An Rx for “ondansetron 8mg” without specifying ODT, oral tablet, or IV solution. Risk: Wrong route administration can lead to therapeutic failure (e.g., giving a non-absorbable drug PO for a systemic infection) or severe harm (e.g., giving an oral solution IV).
Example: Order for “Vancomycin 1 gram.” This must be given IV for systemic infections, but PO for C. difficile colitis. The route is critical.
  1. Check the indication: Why is the drug being ordered? Look at the diagnosis/problem list. A diagnosis of C. diff strongly implies a PO route for vancomycin. A diagnosis of bacteremia implies IV.
  2. Review labs/microbiology: Are there positive blood cultures that would necessitate IV therapy?
  3. Look at patient status: Is the patient NPO? This would make a PO route impossible. Do they have an active IV line?

Ineffective: “What route?”

Effective: “Please clarify the intended route for the Vancomycin 1g order. Patient has a diagnosis of MRSA bacteremia, suggesting the intended route is IV. However, to ensure safety, please confirm route. Will select IV route upon confirmation.”
3. Dose Outside of Standard Range (High or Low) An Rx for “lisinopril 80 mg daily” or “levothyroxine 250 mg daily.” Risk: Toxicity from overdose; therapeutic failure from underdose.
Example: A new order for “Dilaudid 4mg IV” for a 78-year-old opioid-naive female. This is a massive overdose waiting to happen.
  1. TRIPLE CHECK THE PATIENT’S STATUS: Is the patient opioid-naive or tolerant? Review the MAR for any recent opioid administration.
  2. Review previous doses: Have they received this dose before? Was it effective? Did it cause side effects like oversedation?
  3. Check provider specialty: Is this order from the palliative care or pain service (more likely to use high doses) or a new intern (more likely to be an error)?
  4. Consult order details: Did the provider perhaps intend PO route, where 4mg is a more common dose? Was a decimal point missed (e.g., 0.4mg)?

Ineffective: “Dose too high.”

Effective: “For patient safety, seeking clarification on the hydromorphone 4mg IV order. This appears to be a very high starting dose for an opioid-naive elderly patient. MAR review shows no opioids administered in the past 72 hours. A standard starting dose is typically 0.2-1mg IV. Please confirm if this dose is correct or if a lower dose (e.g., 0.5mg IV) is preferred. Holding order until confirmed.”
4. Therapeutic Duplication A patient brings in new Rxs for both lisinopril and losartan from different doctors. Risk: Additive toxicity, increased side effects, potential for severe adverse events.
Example: A patient has an active order for scheduled enoxaparin 40mg daily for VTE prophylaxis. A new order for “apixaban 5mg BID” is entered for new-onset A-fib, but the enoxaparin is not discontinued.
  1. Review the MAR carefully: Confirm both orders are active and scheduled.
  2. Read the provider’s note: Did the provider explicitly state their intention? “Starting apixaban for A-fib, will stop Lovenox.” This indicates an oversight in order entry.
  3. Check administration times: Has the patient already received a dose of both? This increases urgency.
  4. Assess the intent: Was one for treatment and one for prophylaxis? (Rarely appropriate, but possible in complex cases). Is the provider trying to bridge? (Not typical for DOACs).

Ineffective: “Duplicate therapy.”

Effective: “Clarification on anticoagulant orders. Patient has active orders for both scheduled enoxaparin 40mg daily and apixaban 5mg BID. This represents a therapeutic duplication and increases bleeding risk. Assuming the intent is to treat A-fib with apixaban, please confirm if the enoxaparin order should be discontinued. Have pended the new apixaban order awaiting clarification to prevent double-administration.”
5. Allergy Conflict An Rx for Keflex arrives for a patient with a “penicillin” allergy listed in their profile. Risk: Ranging from a minor rash to life-threatening anaphylaxis.
Example: An order for cefepime is entered for a patient with a documented allergy to ceftriaxone described as “anaphylaxis.”
  1. INTERROGATE THE ALLERGY: Do not just read the name. Click on the allergy to see the documented reaction. Is it “hives,” “anaphylaxis,” “nausea,” or “unknown”? This is the most critical step.
  2. Assess cross-reactivity risk: For beta-lactams, review the side chains. The risk of cross-reactivity between penicillins and later-generation cephalosporins is very low (<1-2%) unless the reaction was severe. However, cross-reactivity between cephalosporins with similar R1 side chains is higher.
  3. Talk to the patient: If possible, ask the patient to describe the reaction themselves. “Can you tell me more about what happened when you took ceftriaxone?”
  4. Review previous admissions: Has the patient safely received this or a similar drug in the past despite the documented allergy?

Ineffective: “Patient has ceph allergy.”

Effective: “Regarding the cefepime order, please note patient has a documented allergy to ceftriaxone with a listed reaction of anaphylaxis. Ordering cefepime carries a risk of cross-reactivity and could be dangerous. Please clarify if you wish to proceed despite this risk, or if an alternative agent from a different class (e.g., aztreonam, a quinolone) should be considered based on cultures. Holding order for safety.”
The Danger of the “Informational” Note When Action is Required

A common pitfall for new pharmacists is writing a note that simply states a fact, without asking for action. For example, writing “Note patient CrCl is 25 ml/min” on a full-dose vancomycin order. This is a failure of professional responsibility. You have identified a problem that requires an action (a dose adjustment). Your clarification note must state the problem and clearly ask the prescriber to make a decision or provide a parameter. You must resolve the ambiguity, not just document its existence. Your note should always end with a question or a request for a specific action.

29.1.3 The Recommendation Note: The Tool of Clinical Influence

If the clarification note is about ensuring a baseline of safety, the recommendation note is about elevating the standard of care. This is your primary tool for moving beyond a reactive “error-checking” role into a proactive, influential, and respected clinical expert on the healthcare team. A recommendation note does not question an order because it is unsafe or unclear; it questions an order because there is a clinically superior alternative.

This is where you synthesize your deep knowledge of pharmacology, pharmacokinetics, evidence-based guidelines, and patient-specific factors to propose a change that will improve an outcome. This could mean enhancing efficacy, reducing toxicity, simplifying a regimen to improve adherence, or decreasing the cost of care. Each recommendation note is a business case for better medicine, and you are the lead consultant.

In your retail practice, you do this intuitively. When a patient mentions their statin causes muscle aches, you might call the doctor to suggest switching to a different statin. When a prescription for a non-formulary medication arrives, you proactively call to recommend a covered alternative. You are identifying an opportunity for optimization and proposing a solution. The hospital-based recommendation note is the formal, evidence-backed evolution of this skill.

Masterclass Table: High-Impact Scenarios for Pharmacist Recommendations

The following table details common opportunities to make a clinical recommendation. For each, we will explore the underlying rationale, the critical data you must gather to build your case, and the effective language to persuade the provider.

Scenario for Recommendation The Clinical Rationale & “Why” Data to Gather to Build Your Case Example Recommendation Note Structure
1. Renal Dose Adjustment Rationale: Many drugs are cleared by the kidneys. Failure to adjust doses in patients with Acute Kidney Injury (AKI) or Chronic Kidney Disease (CKD) is a leading cause of preventable adverse drug events and toxicity.
  1. Calculate Creatinine Clearance (CrCl): Use Cockcroft-Gault or MDRD. Note the patient’s age, weight (use actual or adjusted based on policy), and serum creatinine.
  2. Establish a trend: Is the renal function stable, worsening, or improving? A single value isn’t enough. Look at the past 3-4 days of SCr labs.
  3. Consult a dosing reference: Use Lexicomp, Micromedex, or your hospital’s specific renal dosing protocol to find the evidence-based dose for the calculated CrCl.

Problem + Recommendation:

“Recommend dose adjustment for piperacillin-tazobactam based on renal function. Patient’s CrCl has declined to ~25 mL/min (from 60 on admission).

Suggest decreasing dose from 3.375g IV q6h to 2.25g IV q6h per standard hospital guidelines to reduce risk of neurotoxicity and bone marrow suppression. Can make this change if you agree.”
2. IV to PO Conversion Rationale: IV medications are more expensive, carry a higher risk of complications (phlebitis, line infections), and tether the patient to an IV pole. Converting to an oral equivalent as soon as clinically appropriate saves money, reduces risk, and improves patient mobility and satisfaction.
  1. Confirm PO intake: Is the patient reliably tolerating a diet? Check nursing notes and diet orders.
  2. Check for GI issues: Does the patient have an ileus, vomiting, malabsorption syndrome, or are they NPO for a procedure?
  3. Assess bioavailability: Choose an oral agent with excellent bioavailability (e.g., fluoroquinolones, linezolid, pantoprazole, metronidazole). For drugs with poor bioavailability (e.g., IV vancomycin), this is not an appropriate switch for a systemic infection.

Problem + Recommendation:

“Recommend converting pantoprazole from IV to PO. Patient is now on a regular diet and tolerating PO medications.

Suggest changing order to pantoprazole 40mg PO daily. This provides equivalent acid suppression at a significantly lower cost and reduces risks associated with IV therapy.”
3. Guideline-Directed Therapy Optimization Rationale: For many common disease states (Heart Failure, COPD, Post-MI, A-Fib), there are robust national guidelines that define optimal medical therapy. Your role is to identify gaps between the patient’s current regimen and the guideline recommendations.
  1. Confirm the diagnosis: Read the H&P and consult notes to confirm the diagnosis (e.g., Heart Failure with Reduced Ejection Fraction – HFrEF).
  2. Review the guidelines: Be familiar with the cornerstone drugs for that diagnosis (e.g., for HFrEF: an ACE-I/ARB/ARNI, a beta-blocker, an MRA, and an SGLT2 inhibitor).
  3. Identify contraindications: Does the patient have a reason NOT to be on a guideline drug (e.g., history of angioedema for an ACE-I, hyperkalemia for an MRA)?

Problem + Recommendation:

“Recommend addition of guideline-directed medical therapy for HFrEF. Patient has a documented LVEF of 30% and is currently on lisinopril and carvedilol, but not a mineralocorticoid receptor antagonist (MRA).

Per ACC/AHA guidelines, an MRA is recommended to reduce morbidity and mortality. Patient has no contraindications (K is 4.1, SCr 0.9). Suggest initiating spironolactone 12.5mg daily.”
4. Antimicrobial Stewardship (De-escalation) Rationale: Using the narrowest-spectrum, most appropriate antibiotic prevents the development of antimicrobial resistance, reduces the risk of C. difficile infection, and lowers costs. Broad-spectrum empiric therapy should always be narrowed once culture and sensitivity results are available.
  1. Review microbiology data: Find the final culture results. What organism grew? What are its sensitivities?
  2. Compare to current therapy: Is the patient on a broad-spectrum agent (e.g., Meropenem, Zosyn) when the organism is sensitive to something much narrower (e.g., Ceftriaxone, Ampicillin)?
  3. Assess patient status: Is the patient clinically improving? De-escalation is appropriate for a stabilizing patient.

Problem + Recommendation:

“Recommend antimicrobial de-escalation based on final urine culture results. Patient is currently on piperacillin-tazobactam for a UTI.

Urine culture has finalized with >100k E. coli which is sensitive to ceftriaxone. Suggest de-escalating to ceftriaxone 1g IV q24h to provide narrower, targeted coverage and promote antimicrobial stewardship.”

29.1.4 The Education Note: The Bridge to Adherence & Transitions of Care

The education note is your tool for documenting the crucial act of knowledge transfer. While clarifications protect the patient inside the hospital and recommendations optimize their therapy, education empowers the patient for success after they leave. This note captures the content of your counseling sessions with patients and their families, or the training you provide to other healthcare professionals like nurses. It serves as a bridge between the complex inpatient environment and the patient’s next destination, be it home, a skilled nursing facility, or rehab.

This is the most direct translation of your primary role in community pharmacy. Every time you performed a “show and tell” for a new inhaler, explained the INR goals and dietary considerations for warfarin, or conducted a comprehensive medication review, you were performing the actions that belong in an education note. In the hospital, the key difference is that you are documenting this conversation in a shared record, making your efforts visible to the entire team and ensuring the education is reinforced by others.

The Core Principle: Documenting Understanding, Not Just Delivery

An effective education note goes beyond simply stating “Patient counseled on warfarin.” That documents an action you performed, but it doesn’t confirm its success. The gold standard is to document the patient’s comprehension, ideally through the “teach-back” method. A powerful education note proves that knowledge was not only delivered but also received and understood.

Masterclass Table: High-Value Scenarios for Education Notes

The following table outlines key moments where a documented education note is critical. It details the essential points to cover and provides a framework for writing notes that demonstrate true educational value.

Counseling Scenario Essential Counseling Points to Cover & Document Example Education Note Structure
1. New High-Risk Medication (e.g., Anticoagulant)
  • Medication name, indication, and dose.
  • Specific time of day to take it.
  • Major side effects to watch for (especially signs of bleeding/clotting).
  • What to do if a dose is missed.
  • Importance of adherence and follow-up appointments (e.g., for INR checks).
  • Use of the Teach-Back method.

“Patient and wife present for warfarin counseling prior to discharge. Provided education on indication (A-Fib), dose (5mg daily), and importance of consistent timing.

Discussed major signs/symptoms of bleeding (unusual bruising, dark stools) and clotting (leg swelling, shortness of breath) and when to seek medical attention. Emphasized need for regular INR monitoring and consistent Vitamin K intake.

Patient able to teach-back 3 key bleeding signs and verbalized understanding of the need for a follow-up INR check in 3 days. Provided with educational handout.“
2. New Device with Complex Technique (e.g., Inhaler, Insulin Pen)
  • Step-by-step instruction using a placebo/demo device.
  • Have the patient demonstrate the technique back to you.
  • Explain cleaning and storage.
  • Discuss the difference between rescue and controller medications.
  • Confirm patient can perform the physical steps (e.g., has the dexterity to use the pen).

“Provided education to patient on proper use of new Symbicort MDI with spacer for COPD.

Instructed on shaking the canister, priming if needed, full exhalation, slow deep inhalation during actuation, and 10-second breath hold. Also counseled on rinsing mouth after use to prevent thrush.

Patient successfully demonstrated all steps of the technique twice without coaching. Verbalized understanding of using this medication twice daily and albuterol for acute symptoms.“
3. Discharge Medication Reconciliation & Counseling
  • Review the entire discharge medication list with the patient.
  • Explicitly state which home medications were stopped.
  • Clearly explain any home medications that had a dose change.
  • Highlight all new medications and provide brief counseling.
  • Provide a single, clear, consolidated list for the patient to take home.

“Completed discharge medication reconciliation with patient. Reviewed final 12-medication list line by line.

Specifically highlighted that home HCTZ was discontinued and the lisinopril dose was decreased from 20mg to 10mg. Counseled on new prescriptions for apixaban and carvedilol. Patient confirmed they had a sufficient supply of their other chronic medications at home.

Patient verbalized understanding of which medications to stop, continue, and start. Was able to state the new dose of lisinopril. All questions were answered. Provided with an updated medication list.“
4. Nurse Education on Complex Medication Administration
  • Unusual preparation (e.g., reconstitution of a specific antibiotic).
  • Complex administration instructions (e.g., IV push rate for a high-risk drug like labetalol).
  • Stability or compatibility information that is not readily available.
  • Rationale for a non-standard practice.

“Spoke with Jane, RN, regarding administration of IV push levetiracetam. Per hospital policy, the 500mg/5mL vial should be further diluted in 10mL of NS and administered over 5 minutes to reduce infusion-site reactions.

Nurse verbalized understanding of the dilution requirement and the slow push rate. She stated she would proceed with administration as discussed.“

29.1.5 Retail Pharmacist Analogy: The Three Modes of Customer Interaction

A Deep Dive into the Analogy

Mastering the three types of clinical notes is like mastering the three primary modes of interaction you already use with patients and providers in the community setting. You’re not learning a new skill set; you’re learning to formalize and document a skill set you use every single day.

1. The Clarification Note is Your “Problem-Solving Mode.”

Imagine a patient comes to the counter with a prescription that is missing the quantity. Or a patient calls and says, “My doctor told me to stop my old blood pressure pill, but he also gave me a refill for it. What should I do?” In this moment, you enter a reactive, problem-solving mode. You don’t guess. You put the process on hold, pick up the phone, investigate the conflict, get a definitive answer, and document it on the prescription. This is the clarification note: You identify an ambiguity or conflict, halt the process to prevent an error, investigate, and document the resolution before proceeding. It is the foundation of safe dispensing and safe practice.

2. The Recommendation Note is Your “Proactive Advisor Mode.”

Think of a regular patient who you know has a high-deductible plan, coming to pick up a prescription for a branded, Tier-3 medication. You know a therapeutically equivalent, Tier-1 generic is available that would save them hundreds of dollars. You don’t just fill the script. You proactively call the prescriber and say, “I noticed you prescribed Drug X. The patient’s insurance coverage isn’t great for it. Would you consider switching to the preferred generic, Drug Y, to improve affordability and adherence?” This is the recommendation note: The original order isn’t wrong or unsafe, but you use your expertise to identify a superior alternative that improves the outcome—in this case, the financial and adherence outcome. It’s a proactive value-add.

3. The Education Note is Your “Counseling & Empowerment Mode.”

A new patient arrives with their very first prescription for an Ozempic pen and a glucometer. You don’t just put the items in a bag and tell them to read the instructions. You take them to the counseling window. You open the demo pen. You walk them through priming, dialing the dose, attaching the needle, and performing the injection. You have them demonstrate it back to you. You explain the importance of rotating injection sites and what to do if they miss a dose. This is the education note: You are transferring critical knowledge to the patient to ensure they can manage their therapy safely and effectively long after they leave your sight. You are empowering them for long-term success, and a well-written note captures that value for the entire healthcare team to see.