When referring to documentation of patient care activities it is frequently said, “If you didn’t write it down you didn’t actually do it.”  The intended message, for pharmacists and any other health care provider, being the importance of documenting patient care activities to verify services were actually performed.  Furthermore, recording the details of what occurred during a patient encounter helps ensure continuity of care, facilitates quality review, substantiates a claim for payment and provides legal evidence of care provided.  This article is intended to go one step further by discussing how patient care documentation can also serve to create a data management system to support several additional functions related to implementation and delivery of patient services.

DATA ELEMENTS AND USES

But what data should be collected, analyzed and reported?  The answer to this question is dependent upon the specific goals of the service and how the data will eventually be used.  Data that might be useful or desirable to one organization may not be relevant to others.  For discussion purposes the most commonly reported data elements pertaining to patient services can be loosely grouped into six categories as listed in Table 1.  Let’s begin by exploring each category of data and it’s potential service management applications.

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