Ask the Pharmacist: Why Documentation is Important

Ask the Pharmacist: Why Documentation is Important

If it isn’t documented, it didn’t happen.

This is a phrase that most of us in healthcare must live by. Whatever we do or don’t do for a patient — we need to document what was done. If at some point there is a good or bad outcome for the patient, then there is a paper trail as to what was done or not done.

American pharmacist with senior woman in pharmacyOne problem that can sometimes adversely affect a patient and leave a pharmacist with their hands tied is when proper documentation has not been done.

Prescribers are not always “honest” with the directions that they put on a patient’s prescription and what they verbally tell the patient.

Sometimes they tell the patient, after the fact, that they can take an extra dose because the original directions are not “doing the job.” The prescriber may not document those added instructions in the patient’s medical records.

Recently I was contacted by a chronic pain patient, whose doctor had initially prescribed a twice a day dose of an opiate to manage their pain. After a short period, the patient contacted the doctor and the patient was advised to take a third daily dose if needed.

As the patient took additional doses and began to run out of pain medication, the doctor was contacted for another written prescription, which the doctor promptly provided with the same direction of twice a day dosing!

It is not known if the doctor failed to document the additional dose or if they didn’t reference the patient’s records when writing the new prescription.

As luck would have it, this was a Friday. The pharmacist and/or insurance company refused to fill the new prescription, because the patient should not have been out of medication for another few days, according to all the documentation they had.

Making matters even worse, the doctor was now on vacation and couldn’t be reached – leaving the patient with no pain medication for the weekend.

To help patients avoid this sort of situation, I recommend to patients that they make notes before they call their doctor and take the notes with them to an appointment. Doctors are pressed for time, and the discussion between doctor and patient may get off track, with the most important points that the patient wants to discuss not getting addressed.

When the doctor hands you a prescription, don’t just fold it and put it in your pocket. Look at it and read it! If what is on the written prescription is not clear to you, ask questions before you leave the doctor’s office.

If you have to contact the doctor’s office for a prescription request, send in your request via fax, email or text. That way, when the doctor gets ready to write the prescription or call it in to a pharmacy, they have all the necessary information in front of them to help “get it right”.

Remember that your doctor typically sees 30 or more patients each day, and may also have to field hundreds of calls, emails or texts. Your prescription request is just one data point and/or request that needs to be dealt with that day.

Surely, your doctor is extremely intelligent, but they’re still human. Help them make sure that you get what you both want you to have.

Steve Ariens

Steve Ariens

Steve Ariens is a retired pharmacist and patient advocate who has a blog called Pharmacist Steve. Steve’s wife is a chronic pain patient.

If you have a question for Steve, send it to

The information in this column is not intended to be considered as professional medical advice, diagnosis or treatment. Only your doctor can do that!  It is for informational purposes only and represents the author’s personal experiences and opinions alone. It does not inherently or expressly reflect the views, opinions and/or positions of National Pain Report or Microcast Media.