Teaching Pharmacy Students to Write in the Medical Record

To practice pharmaceutical care, pharmacists will need to communicate and document their recommendations in the medical record. We incorporated instruction on the principles of chart documentation into an elective on primary care therapeutics. Students developed a patient specific care plan and wrote a “chart note” to document their assessment and recommendations. Performance criteria for notes were developed for formative and summative assessments. The notes were useful in assessing students’ understanding of therapeutic principles and introducing the concepts and importance of chart documentation, but additional practice would be necessary to achieve a “chart-ready” note. Developing this ability is a complex process, requiring instruction, opportunities to practice, constructive feedback, opportunities for revision and an appreciation for the its importance. Pharmacy curricula should include an organized, uniform and efficient method of teaching professional documentation.