clinical-pharmacy-assessment-report

Assessment & Findings Report — Clinical Pharmacy

Assess patients with complex medication needs and prescribing teams and write a defensible findings report as a clinical pharmacist. The deliverable is a structured assessment report with findings, evidence and recommendations. This skill is written for a clinical pharmacist working with patients with complex medication needs and prescribing teams in hospital wards and clinics.

When to use

• You are a clinical pharmacist preparing, delivering or reviewing this part of your work in hospital wards and clinics.
• You need a defensible, repeatable approach that produces a structured assessment report with findings, evidence and recommendations.
• A colleague, auditor or client asks how this was done and what evidence supports it.

Key Concepts

Term	Meaning
Polypharmacy	the use of many medicines by one patient
Formulary	the approved list of medicines for an organisation
Titration	adjusting a dose gradually to effect

Workflow

1. Step 1 - Review the intake record and medication reviews so the assessment builds on verified information, not assumptions
2. Step 2 - Carry out the assessment using electronic prescribing systems, following the recognised method for hospital wards and clinics
3. Step 3 - Compare findings against the benchmarks behind medication review completion and note where evidence is strong, weak or missing
4. Step 4 - Draft the report: findings first, then interpretation, then recommendations in priority order
5. Step 5 - Check the draft for accuracy and for dangerous interactions missed; have it reviewed where the profession's standards require a second sign-off

Profession-Specific Components

Component	Details for Clinical Pharmacy
Core documentation	medication reviews; prescription charts; intervention logs; discharge medication lists
Core tools & equipment	electronic prescribing systems; medicines reference databases; inhaler technique devices; tablet counters
People involved	patients with complex medication needs and prescribing teams; the clinical pharmacist; colleagues and other services in hospital wards and clinics
Primary record	medication reviews — keep it current, dated and attributable

Output Format

Context: [Situation in hospital wards and clinics] | Objective: [What this must achieve] | Audience: [patients with complex medication needs and prescribing teams and other stakeholders]

The finished output is a structured assessment report with findings, evidence and recommendations, structured as:

1. Summary of position and evidence
2. Detail, following the workflow above
3. Decisions, actions, owners and dates
4. Review point and escalation route

Action Plan

1. Immediate: Confirm scope, consent and the evidence available in medication reviews.
2. Short-term: Complete the workflow steps and record outcomes against medication review completion.
3. Medium-term: Review results, close actions, and update local procedures in hospital wards and clinics.

Success Metrics

Metric	Target	Method
medication review completion	Agree a local target and track the trend	Measured from medication reviews and reviewed on a set cycle
prescribing error interception rate	Agree a local target and track the trend	Measured from medication reviews and reviewed on a set cycle
discharge delay due to medicines	Agree a local target and track the trend	Measured from medication reviews and reviewed on a set cycle
patient counselling rates	Agree a local target and track the trend	Measured from medication reviews and reviewed on a set cycle

Guardrails & Quality Checks

• Never let this happen: dangerous interactions missed.
• Never let this happen: look-alike medicine confusion.
• Never let this happen: discharge medicines errors.
• Work only within the competence and authority of a clinical pharmacist; escalate or refer anything beyond it.
• Record facts and observations, not speculation, and keep records confidential to hospital wards and clinics's rules.
• Verify names, dates, figures and measurements twice before anything is issued or signed off.
• Use only real, verified information from the case in hand — never invent results, credentials or evidence.

Example (illustrative)

A clinical pharmacist in hospital wards and clinics applies this workflow for patients with complex medication needs and prescribing teams: they open medication reviews, work through the five steps using electronic prescribing systems, and close by recording the outcome against medication review completion and agreeing the next review date. (Illustrative example only — replace with the real details of the case in hand.)