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Improving medication management through health informatics information technology: The feasibility of representing pharmaceutical care services information using the Omaha System
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Objective: To assess the feasibility of representing pharmaceutical care services information using the Omaha System.
Methods: Two clinical experts, from nursing and pharmacy, mapped 10 de-identified pharmaceutical care services SOAP note narratives from an integrated ambulatory care clinic to the Omaha System using concept mapping methods. Clinical pharmacy and Omaha System experts validated the mapping results.
Results: In total, 9 Omaha System problems were mapped to the SOAP note narratives. On average patients had 4 medication-related problems, 6 signs/symptoms, and received 3 pharmacist-initiated interventions. The most commonly addressed problems in the sample were Medication Regimen, Substance Use, and Respiration. Gaps in documentation were identified in the narratives regarding appropriate monitoring and follow-up activities.
Discussion/Conclusion: Mapping pharmaceutical care services SOAP note narratives to the Omaha System was feasible and has potential to communicate pharmaceutical care diagnoses, interventions and patient outcomes. This will enable a more comprehensive and standardized data collection for the evaluation of cross-disciplinary clinical decision-making and improve communication across health care settings.
Learning Areas:
Clinical medicine applied in public healthCommunication and informatics
Other professions or practice related to public health
Provision of health care to the public
Learning Objectives:
Identify key components of the Omaha System within pharmaceutical care services SOAP notes.
Differentiate between SOAP narrative and Omaha System documentation practices.
Discuss strategies for improving cross-disciplinary clinical decision-making communication.
Keyword(s): Information Technology, Pharmacists
Qualified on the content I am responsible for because: I have been the principal or co-principal of multiple studies and developmental programming focusing on the implementation and evaluation of documentation practices of pharmaceutical care services. Among my scientific interests has been the development of strategies for improving cross-disciplinary clinical decision-making communication for providing and improving patient-centered care.
Any relevant financial relationships? No
I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.