Insufficient/Missing Clinical Notes Yield Audit Recoupments

Inevitably, pharmacies will receive prescriptions that contain missing elements or need clarification. To avoid a potential recoupment, clear documentation is essential.

PAAS recommends four elements for clinical notes:

1. Date (and preferably time) of the call/conversation
2. Name and title of who you spoke with
3. Specific details about the clarification
4. Initials or name of the pharmacy employee making the clarification

PAAS Tips:

• Instruct staff and have a policy on how clinical notes will be documented
• Some pharmacies have created customized ink stamps to facilitate and promote this documentation process for staff
• Check with your software vendor on how to utilize the electronic notes field
• If making handwritten clinical notes, ensure you rescan the prescription into your software
• Any notations made on previous prescriptions that are still valid should be carried forward to the new prescription
• If the patient instructions are clarified, ensure the patient label is updated prior to dispensing to reflect the new directions
• Upon an audit, be sure all clinical notations are clearly visible to the auditor
• See the June 2023 Newsline article, Carry Clinical Notes Forward for Audit Coverage
• See the August 2023 Newsline article, Electronic Clinical Notes: Are They Required?