DR.

PJGMRMC CLINICAL PHARMACY

TRAINING PROGRAM – BATCH 3
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Medical Record
Orientation and
Coordination
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OBJECTIVES

 At the end of this session, participants will be able

to:
 Define medical record

 Enumerate the DO’s and DON’Ts in handling medical

record
 Have a glimpse on DPA 2012

 and state the roles of each HCW in coordination of

efficient drugs & medicines provision to clients
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 WHAT IS
MEDICAL
RECORD?
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MEDICAL RECORD

 The record of care that is provided and given to a

patient.

 It means all communications related to a patient’s

physical or mental health or condition that are
recorded in any form or medium and that are
maintained for purposes of patient diagnosis or
treatment, including those that are prepared by a
health care provider or by other providers.
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MEDICAL RECORD

 “When you document effectively, your patient’s

medical record reflects your professionalism.”
(Seeber-Combs, 2006, p.1)
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DO’s and DON’Ts in HANDLING
MEDICAL RECORD
 Do uphold client’s privacy and confidentiality based on
Republic Act 10173 (Data Privacy Act of 2012)

 Do follow institutional or hospital guidelines in using

medical records (DOH Hospital Health Information
Management Manual, 3rd Edition, 2010)

 Do write/sign your own name and signature when

inscribing in any part of the medical record – shows
accountability
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DO’s and DON’Ts in HANDLING
MEDICAL RECORD
 Do use hospital protocol in correcting mistaken entry

 Do write legibly and use appropriate ink color as

prescribed

 Do check patient identifiers prior to writing to any part

of the medical record

 Do verify, coordinate and collaborate with other HCW

(e.g. nurse and doctors) regarding any entry
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DO’s and DON’Ts in HANDLING
MEDICAL RECORD

 Don’t make or sign entry for someone else

 Don’t alter chart – THAT’S A CRIMINAL OFFENSE

 Don’t cover up a mistake or incident – by omission or

use of correction fluids or any other forms

 Don’t leave medical records unattended or within

reach of unauthorized person
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 WHY PROTECT
MEDICAL
RECORD?
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IMPACT

 Loss of reputation

 Loss of market share

 Legal liabilities
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DATA PRIVACY ACT OF 2012

 An act protecting individual personal information in an

information and communications system in the
government and the private sector

 Encompasses protection of all types of data

information that can lead to identity of a person such
as personal information, sensitive personal
information and privileged personal information
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DATA PRIVACY ACT OF 2012

 Institutions either public or private shall have a data

sharing agreement between client’s and
stakeholders, use of consent, adhere to data privacy
principle, upholds the rights of data subjects, and
implement security measures for the protection of
client information
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 WHY NEED TO
COLLABORATE OR
COORDINATE?
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BENEFITS OF COORDINATION OR
COLLABORATION

 Promotes Medication Safety practices

 Prevents medication errors

 Prevents legal liabilities

 Promotes efficiency in health care services

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 WHAT ARE THE PERTINENT

FORMS WHERE NURSE
AND PHARMACIST
COLLABORATE/
COORDINATE?
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MEDICAL FORMS

 Physician’s Order Sheet

 Medication Sheet

 IV Fluid Sheet
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PATIENT SAFETY

 Defined as the prevention of harm to patients through

avoidance and amelioration of risk, adverse
outcomes, or injuries stemming from the processes of
healthcare.

 It is the degree to which the risk of an intervention

and risk in the care environment are reduced for a
patient and other persons including healthcare
providers.
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PATIENT SAFETY

 Through strategies that promote patient safety,

hospital management and health care providers are
able to prevent sentinel events such as medication
errors in any forms, either direct or indirect.
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MEDICATION ERRORS

 Is broadly defined as dose of medication that deviates

from the physician’s order as written in the patient’s
chart or from standard hospital policy and
procedures.
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MEDICATION ERRORS
 Upholds the key elements of patient safety through:

 Strong leadership and political commitment,

 Institutional development,

 Institutionalized reporting system of any committed errors,

 Appropriate feedback and communication,

 Adverse event prevention and risk management,

 Disclosure of reported serious events,

 Professional development, and

 Patient-centered care and empowerment of consumers/clients.

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 HOW DO WE
COORDINATE OR
COLLABORATE?
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 Both nurses and pharmacists work in a stressful

environment in the hospital, with increasing demands
from clients and unfamiliarity with each others work
processes and procedures. W. Watt, 2021

 Nurses play an important role in developing a

collaborative relationship with pharmacist…a nurse can
give valuable information to the latter to optimize
therapeutic plan as per patient needs. Oman Med J.
2014
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STRATEGIES TO STRENGTHEN
RELATIONSHIPS
 Establish decentralized pharmacy

 Meet regularly for a more clearer and effective

communication

 Job shadowing

 Share hiring and recruiting duties

 Participate in interprofessional educational

opportunities
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 Collaboration
produces patient
benefits. W.Watt, 2021
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WHAT DO WE DO?
 Verify written orders

 Double check transcribe drugs and medicines in the

physician’s order sheet

 Call attention of doctors professionally and politely

 Make appropriate notes or marks on chart to notify nurses

and doctors

 Inform doctors and nurses regarding availability of drugs,

medicines and other pharmaceutical supplies
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WHAT DO WE DO?
 Supply station with updated list of available drugs, medicines
and supplies in the pharmacy

 Call attention of staff nurse or unit supervisor regarding

monitoring of regulated drugs, expired drugs in the unit, and
returned issued drugs

 Provide orientation to HCW (e.g. nurses and physicians) on

the protocols of pharmacy department regarding requisition,
dispense or issuance, monitoring, return and disposal of
expired items
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IN SUMMARY:
 Medical record should be handled appropriately with
confidentiality

 All healthcare providers must follow the hospital protocols in

managing medical record

 Coordination and collaboration amongst HCW prevents

medication errors and promotes patient safety in the workplace

 Working together produces better patient service outcomes

 Understanding each other’s roles in the workplace creates

improved communications between HCWs
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Thank you

 “When nurses and pharmacists

collaborate, they form a respectful
relationship that recognizes the
valuable efforts each deliver – and
patients ultimately are the
beneficiaries.” (W. Patt, 2021)