Magazine article Drug Topics

The Importance of Documentation

Magazine article Drug Topics

The Importance of Documentation

Article excerpt


When he received the telephone call, Jeff had been a pharmacist for more than 20 years. It was a call he will never forget.

The call was from a pharmacy patient well known to Jeff, an elderly lady being treated for heart problems. Among the other prescription medications she took was digoxin 0, 1 mg. Jeff had filled this prescription for her about a week earlier, As Jeff answered the phone, it was obvious to him that his patient was crying.

She asked, "Jeff, why did you put my digoxin prescription in that easyopen bottle?" Jeff presumed that the patient had requested an easy-open cap, but he did not remember the incident. He had filled a lot of prescriptions in the previous week.

Jeff pulled the prescription from the file and noted the statement rubber-stamped on the back: "I request that my prescription be filled in a non-child-resistant container," It was signed by the woman he was speaking with on the phone.

When he told her about the notation on the back of the prescription, she began crying harder and said, "I was hoping it was your idea, Jeff, I am at the hospital. My little grandson got into my purse, He died a few minutes ago."

Consequences of negligence

With only a few exceptions, if a pharmacist dispenses a prescription in a non-child-safe container without a request from a patient or physician, it is a violation of federal law That may amount to negligence per se -negligence without further proof. It could result in additional, punitive damages.

In this case, there was no lawsuit, because Jeff had proof of what happened the day that the prescription was filled. Without that proof, Jeff's attorney could have argued "custom and habit" evidence, even though Jeff did not remember filling the prescription. Lawyers will tell you, however, that "custom and habit" is a weak defense when the jury is confronted with a dead child and a grieving grandmother.


Documentation need not be long or in complete sentences. It must be sufficient to provide clear proof of what was done or said. Discoverable documentation should be factual and without opinions or speculation. Some CQI records may be protected from discovery and, if so, opinions in that case may be appropriate. …

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