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Toolkit: Patient Encounter Documentation

Below is a list of resources that can be used as a reference for the documentation of patient encounters in the pharmacy:



- Community and Clinical Pharmacy Services: A Step-by Step Approach

This book describes practical ways for pharmacists to provide advanced levels of pharmacy services, in community and clinic settings, designed to help patients achieve specific health goals and treat common disease states. 

McGrath SH, Holliday SS. Documentation. In: Ellis AW, Sherman JJ. Community and clinical pharmacy services: a step-by step approach.  New York: McGraw Hill; 2013. 

View this book here.


- Documentation of Pharmacy Services

This chapter discusses the types of patient information to document, how to communicate documentation, documentation systems, training considerations, and use of support staff in documentation.

Mackinnon III GE, Mackinnon NJ. Chapter 7. Documentation of pharmacy services. In: DiPiro JT, Talbert RL, Yee GC, et al., eds, Pharmacotherapy: a pathophysiologic approach,. 8th ed. New York, NY: McGraw-Hill; 2011.  

View this chapter here.


- How to Conduct a Comprehensive Medication Review: A Guidebook for Pharmacists

This guidebook assists pharmacists with implementing MTM, emphasizing the patient encounter including providing examples of documentation forms.

Angelo, Lauren B., and Jennifer Cerulli, How to conduct a comprehensive medication review: a guidebook for pharmacists. Washington, D.C: American Pharmacists Association, 2014.

View the guidebook here.


- Pharmaceutical Care Practice: The Patient-Centered Approach to Medication Management Services

This book provides basic information necessary to establish, support, deliver, and maintain MTM services. This practical guide includes a pharmacotherapy workup form to document encounters. 

Cipolle, Robert J., and Peter C. Morley. Pharmaceutical care practice. New York: McGraw-Hill, 2012.

View this book here.


- Medication Therapy Management: A Comprehensive Approach

This chapter provides information and an approach to documenting MTM services in any setting. While the emphasis is on Medicare-funded MTM, the concepts can be applied universally by viewing Medicare as any other health insurance plan with a drug benefit.

Angaran DM. Documentation. In: Angaran DM, Whalen K. eds. Medication therapy management a comprehensive approach. New York,: McGraw-Hill Education; 2014.

View this chapter here.



The National Association of Pharmacy Regulatory Authorities resource page contains many example forms to document pharmacist interventions.

Click here.

This toolkit is beneficial to providers interested in implementing MTM programs, especially those with a research component. The tools are validated and have strong application for research. The toolkit has good application to MTM service delivery, and the tools are easily modified and integrated into daily practice.

View this toolkit here.


Online Documentation Systems

Some currently available electronic systems that can help with documentation and/or billing for MTM services:


MirixaPro from the National Community Pharmacists Association (http://www.mirixa.com)


Outcomes MTM System from Outcomes Pharmaceutical Health Care (http://www.outcomesmtm.com/)


ConXus MTM from Protocol Driven Healthcare, Inc. (www.pdhi.com)


Medication Management Systems/Assurance Pharmaceutical Care Documentation Software from the University of Minnesota Peters Institute of Pharmaceutical Care (http://www.medsmanagement.com)


Medication Pathfinder from Clinical Support Software (www.medicationpathfinder.com)


MTM 360 from Elsevier Clinical Decision Support (http://www.goldstandard.com/wp-content/uploads/2011/08/MTM360.pdf)


PharmMD from PharmMD (www.pharmmd.com)


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