Introduction & module overview

Making a concise clinical record of a consultation is increasingly becoming a necessary skill for community pharmacists. For example, when supplying treatments via patient group directions or making clinical decisions on the conditions covered by the Pharmacy First service, pharmacists are required to keep a record of their consultations with patients.

The intention is to incorporate this information in a patient’s NHS care record through systems such as GP Connect in England and Choose Pharmacy in Wales. The data that pharmacists are required to enter must include an explanation of the basis for any clinical decisions.

Current challenges include using free text in clinical summary records (rather than structured computer entries), ensuring records are concise and relevant, and sustaining rapport with the patient while contemporaneously recording key information.

The use of messaging software to communicate with patients before and after a consultation offers opportunities for providing better patient-centred information as well as efficiencies in identifying patients eligible for Pharmacy First and similar services in the UK.