Clinical decision making and prescribing support for CPIPs - Documentation is key

Aug 31, 2026

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Clinical decision making and prescribing have become central to daily Community Pharmacy practice, especially with Pharmacy First and Pharmacy First Plus alongside PGD use. The guidance emphasizes how CPIPs can safeguard patient care and safety by reflecting on prescribing judgments, documenting actions, and justifying decisions if an error or query arises. It also outlines why documenting consistently matters, provides practical approaches for review and evidence, and highlights required tools, resources, and an audit pathway.

LanguageEnglish

CategoryLetters

FormatDOCX

Pages6

Reading Time2 min

AccessFree to download

Clinical decision making and prescribing

Documentation and justification

Reflecting and reviewing practice

Equipment and keeping up to date

Tools and devices

Formulary and resources

Practical support for prescribing

Condition checklists and contact details

Patient leaflets and safety netting

Documentation is key Lorna Brown in conjunction with David Massie Clinical decision making and prescribing are becoming increasingly integral to daily Community Pharmacy practice. With the introduction of Pharmacy First and Pharmacy First Plus alongside PGD use, comes an increase in potential for prescribing and judgement errors that can affect both quality of care and patient safety. To help CPIPs ensure that they are safeguarded and supported within their role we are highlighting this topic and suggesting ways for pharmacists to reflect on their clinical decision making and prescribing decisions alongside giving guidance on how to document your actions. Should an error or query be identified, you will be required to evidence the investigations/questioning you undertook that resulted in the decision to prescribe (or not prescribe). It is not expected that all decision making will be perfect. However, it is expected that the pharmacists, like other prescribers will be able to justify their decision to others if required. Increased documentation is an additional string required for the CPIPs bow. Documentation can vary depending on many factors including operating system functionality, how your colleagues document and/or how your DMP documented during your PLP. All can affect positively or negatively your documentation process. If you are grappling with the best way to document and communicate – why not consider a visit to your local Teach and Treat Training Hub? Take along an example of your process/paperwork for discussion. Alternatively speak to your peers or colleagues if you work for a multiple, others might have unearthed some smart solutions that could help. Reviewing your work, will give you the opportunity to reflect on prescribing and identify any areas that are working well and any areas for improvement. It can also enable you to identify any possible reasons for an error occurring and consider methods for avoiding similar errors in future. As a new prescriber it might be an idea to review some of your prescribing or ask someone else to do this for you. Check that you can make sense of what you did and why and if possible that someone else agrees. It could be an idea to do this sooner rather than later so that any potential bad habits or issues are identified early in your prescribing journey and can be rectified. When making clinical decisions the risk versus benefit must always be considered before making a recommendation or issuing a prescription. Before prescribing, some of the themes in the image above should be considered so that you can justify your decision if required to do so. If you wish to undertake a review of your prescribing and need some support to get started, please contact the CPDT or ask a peer. There is an audit template available to help you complete an audit of your prescribing/documentation. Perhaps you could review 5-10 Rx for a fellow CPIP and they could do the same for you? What Equipment do I need and how do I keep up to date? By Maxine McCabe We first started offering a Common Clinical Conditions clinic at Parkhead Health Centre Pharmacy in 2019 as part of a pilot. We are located beside 2 GP practices, and they were helpful when we started and were working out what equipment we needed to provide the service. The list below is what I would recommend for anyone starting up a Pharmacy First Plus service. There are also numerous gadgets available that can help with specific issues e.g., Stethoscopes with amplifiers for those with hearing issues and apps that allow you to view the otoscope image on a phone or screen to use in your discussion with the patient. If you find a great device or gadget that helps with consultations, share it, if it makes your life easier then pass it on. *Apron*Gloves *Tongue depressors *Electronic BP monitor (including additional large cuff) *Otoscope including covers (we use Heine. Remember to check the cover size is not too big for children) *Ear therm

FAQs

Why has documentation become increasingly important for CPIPs?

With Pharmacy First and Pharmacy First Plus and PGD use, prescribing and judgment errors can affect care quality and patient safety. Increased documentation helps pharmacists evidence investigations and justify decisions if queried.

What should a CPIP do if an error or prescribing query is identified?

The CPIP is expected to evidence the investigations and questioning undertaken that led to the decision to prescribe or not prescribe, and be able to justify the decision to others if required.

What practical items and resources are recommended to support Pharmacy First Plus consultations?

The guidance recommends appropriate equipment (such as gloves, BP monitor, otoscope, ear thermometer, stethoscope, pulse oximeter) and familiarization with resources like SIGN and NICE, plus formulary updates to keep prescribing current.

Aug 31, 2026

Upload by Jacob