PEBC MCQ Communication, Collaboration & Documentation question: prescriber reduce the gabapentin dose

PEBC MCQCommunication, Collaboration & Documentation

A pharmacist recommends that a prescriber reduce the gabapentin dose of a 79 year old patient whose creatinine clearance has fallen to 28 mL/min. What should the pharmacist document?

a. The recommendation and the new dose, once the prescription is changed
b. A summary of the counselling given to the patient on the new dose
c. The problem, recommendation, prescriber reply and follow-up
d. The prescriber's reply, filed with the original prescription only

Show the answer and explanation

Answer: c. The problem, recommendation, prescriber reply and follow-up

Complete documentation of a clinical intervention records the drug therapy problem (with the kidney function value), the recommendation made, the prescriber's response and the follow-up plan, so that colleagues can see the reasoning and continue care. Recording only the new dose, only the prescriber's reply or only the counselling leaves out the assessment and the plan, which NAPRA's standards expect to be documented. Source: NAPRA Model Standards of Practice for Pharmacists and Pharmacy Technicians in Canada (2022), Standard on documentation.

Common mistake

Not documenting clinical interventions.

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