Ergebnisdokumentation

Ergebnisdokumentation is the sheet a pharmacy fills in after it has measured something or collected a sample. It is the only trace the service leaves once the customer has left the shop, because a value read aloud and remembered is not a record. A number written on the back of a receipt is not a record either, since nobody can say afterwards who wrote it, when, or on which device. A standard form is better than a blank sheet for a dull reason, because it asks the same questions in the same order every time. An empty field is then visible to anyone who picks the sheet up.

The content is short and fixed, and the same six things belong on every finished form:

• The person is identified by more than a first name, so the pharmacy could still confirm months later who it was.
• The date and the time are written down, because a value without a time cannot be compared with a meal, a medicine or a second measurement.
• The name of the person who performed the act belongs on the form, because a pharmacy has to be able to say who stood there.
• The device or the laboratory used is identified by instrument or by request number, so the measurement can be traced back to a system that was under control that day.
• The result itself is either the value the device produced or the plain fact that a sample was taken and sent.
• What the customer was actually told goes on the form as well.

That last field is the one most often left blank and the one that matters most. The pharmacy records that it handed over a value and advised the person to take it to their physician. It does not record a conclusion of its own. A number outside a Referenzbereich is a reason to refer and nothing more, so the form should read that way. The wording of the referral sentence belongs in the Standardarbeitsanweisung so that every member of staff says and writes the same thing.

The form is also what protects the pharmacy later, because a complaint months afterwards is answered from the file or it is not answered at all. For a pharmazeutische Dienstleistung the documentation is part of what is being paid for, so the billing and the defence depend on the same sheet. Once it is signed it becomes patient documentation and comes under the Aufbewahrungsfristen for health records, which are longer than the periods a retail business is used to.