Electronic Clinical Progress Notes as Performance Indicators in Clinical Pharmacy: A Validation Study

Gustavo Cassiano da Silva; Mario Vianna Vettore; Renato Fuller; Lavinia Cosmina Ardelean

doi:10.51847/n2YuL8SLvh

Author(s)

Gustavo Cassiano da Silva Department of Postgraduate in Health Sciences, Medical School, Federal University of Goiás, Goiânia, Goiás, Brazil

Mario Vianna Vettore Department of Postgraduate in Health Sciences, Medical School, Federal University of Goiás, Goiânia, Goiás, Brazil

Renato Fuller Department of Postgraduate in Health Sciences, Medical School, Federal University of Goiás, Goiânia, Goiás, Brazil

Lavinia Cosmina Ardelean Department of Postgraduate in Health Sciences, Medical School, Federal University of Goiás, Goiânia, Goiás, Brazil

Abstract

Hospital clinical pharmacy teams contribute to safer, more effective, and cost-conscious medication use. Evaluating the extent and impact of these services is vital for ensuring care quality, but conventional performance tracking through manual reporting is resource-intensive. This study investigated whether electronic medical record (EMR) progress note counts could reliably indicate clinical pharmacy activity. A sample of 300 adult patient admissions across three Australian hospitals (May-November 2021) was examined. Pharmacy-authored EMR notes were categorized according to their titles and the interventions documented. Using a manual audit as the reference standard, the validity of note counts was assessed via sensitivity, specificity, and positive predictive value. Among 861 audited notes, entries labeled PMM Medication History, PMM Medication Review, and PMM Discharge Medications exhibited strong agreement with manually verified interventions, showing high specificity and predictive accuracy (> 98%) and sensitivities of 98%, 90%, and 89%, respectively. These findings support the use of EMR progress note counts as an accurate, efficient measure of clinical pharmacy service delivery. This approach offers a scalable solution for hospitals seeking streamlined performance assessment. The study received ethical clearance from the Central Adelaide Local Health Network Human Research Ethics Committee (Ref. 16357) and the University of South Australia Human Research Ethics Committee (Ref. 205782), in line with national ethical standards.

Publication Details

Page(s) 17-20

DOI 10.51847/n2YuL8SLvh

Published Journal: Archives of Pharmacy Practice, Volume: 16, Issue: 4, Year: 2025

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Keywords

Healthcare quality, Clinical pharmacy, Hospital Services, Medication management, EMR, Performance evaluation

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