Introduction

Structured documentation is critical for safe and effective medication management in the Intensive Care Unit (ICU), where patients are often clinically complex and treatment regimens rapidly evolve. Pharmacist-written Medication Management Plans (MMPs) play an important role in multidisciplinary care by supporting therapeutic decisions and ensuring continuity across shifts and teams. However, differences in the structure, content, and presentation of these notes can affect their overall readability, perceived bulk, and flow—factors that are particularly relevant in long-stay patients where information accumulates over time.

This audit examined the structure and consistency of ICU documentation across multiple hospital sites, focusing on four core domains:

1. Background Information: We reviewed the inclusion and structure of key patient presentation details in ICU pharmacist Medication Management Plans (MMPs), focusing on elements such as the History of Presenting Complaint (HOPC), Past Medical History (PMHx), and objective data (e.g. observations, pathology). We also assessed whether active clinical issues were documented and, if so, whether they were separated under a distinct heading to improve visibility. While pharmacy MMPs lack a standardised structure, this section broadly reflects the “Subjective” component of a SOAP framework, providing clinical context for medication decisions.

2. Medication Reconciliation: We examined how pharmacists structured and documented medication-related content within the inpatient ICU MMP. The audit focused on how new medications were recorded (including use of dates), how changes were tracked over time, and how therapies were grouped or compartmentalised. This section reflects the core function of the MMP, capturing pharmacist-led medication reconciliation and the evolving medication history during the ICU admission.

3. Formatting and Visual Aids: We reviewed how formatting was used to support clarity and consistency in the ICU MMP. This included approaches to documenting ceased therapies, use of date stamps, indication formatting, and visual cues such as greying out or coloured text. These elements contribute to the readability and usability of pharmacist documentation.

4. Quantitative Metrics: We assessed documentation patterns using several quantitative measures. These included the average word count per MMP entry, the average number of subheadings used, changes in word count over time for long-stay patients, and the average time between pharmacist entries. These metrics provide insight into documentation variability, structure, and how information evolves throughout an ICU admission.

Aim

To evaluate how ICU MMPs are structured, organised, and formatted across multiple sites, using a thematic framework. The goal is to identify patterns and inconsistencies that can inform future improvements in documentation quality, usability, and standardisation in ICU pharmacy practice.

Methods

This was a retrospective audit of inpatient MMPs documented by ICU pharmacists across multiple hospital sites. The audit evaluated each MMP as an independent unit of analysis, using a thematic framework covering four domains: Clinical Information, Medication Reconciliation, Formatting and Visual Aids, and Quantitative Metrics.

Inclusion Criteria

MMPs were included if they were:

  • Written for adult patients admitted to the ICU, and

  • Completed between 1st March and 5th April 2025, inclusive.

Both long-stay and short-stay ICU patients were included to capture a range of documentation styles and patterns. MMPs with clearly defined structure, complete medication sections, and accompanying clinical narrative were eligible for analysis.

Data collection

MMPs were manually reviewed and scored using a structured audit tool developed for this project. The tool captured both binary and numeric variables across four core domains: clinical information, medication reconciliation, formatting features, and quantitative metrics. Additional free-text comments were recorded in a miscellaneous column to capture unstructured observations or one-off patterns.

Data were transcribed into Microsoft Excel and subsequently cleaned and prepared for analysis in R.

Analysis

Descriptive statistics were used to summarise the presence of key documentation features, the number of medication subcategories, and word count per MMP entry. Patterns in structure and formatting were explored using thematic analysis. Quantitative measures, including average word count and time between entries, were used to assess variability in documentation over time.

Analysis was conducted using Excel (Microsoft 365) and RStudio (R version 4.3.1), utilising functions from the dplyr, ggplot2, and stringr packages for data wrangling and visualisation.

Results

Overview

A total of 40 ICU MMPs were audited, representing documentation from four hospital sites and authored by 13 different pharmacists. The sample included a mix of long-stay and short-stay ICU patients, with MMPs completed between 1st of March and 5th of April 2025. Each MMP was evaluated using a structured audit tool capturing variables across four thematic domains: clinical information, medication reconciliation, formatting features, and quantitative metrics. This provided a snapshot of documentation patterns and structural variation across a diverse range of ICU cases.

1: Background Information

Figure 1 illustrates the proportion of ICU MMPs that included key elements of background information. The left panel (“History and Context”) shows high inclusion rates for presenting complaints (HOPC, 90%) and past medical history (PMHx, 75%). However, objective clinical data such as vitals or investigations were documented in only 20% of cases.

The right panel (“Inpatient Issues”) shows that clinical issues were documented in 90% of MMPs; however, only 28% presented them under a distinct heading. In most cases, issues were embedded within the History of Presenting Complaint (HOPC) section rather than listed separately.

2. Medication Reconciliation

2.1 Additional Subheadings:

Figure 2 demonstrates additional subheadings—beyond those provided in the standard .phainpat template—were added under the “New Medications” section in 80% of MMPs. This reflects a common workaround by ICU pharmacists to better organise complex therapy areas not supported by the default structure.

3. Formatting and Visual Aids

3.1 Tracking Changes

Figure 3 displays how changes to medications were documented in ICU MMPs. Greyed-out formatting was used in 38% of MMPs to indicate ceased medications, while 19% explicitly included a cessation date at the end of the line. In some cases, pharmacists applied both conventions, and a few added start and stop dates at the beginning of the medication entry. While these strategies aim to improve clarity—especially for long-stay patients—there was noticeable variation in how these changes were documented across MMPs.

Figure 4 shows that 35% of MMPs used a structured dd/mm: style to format dates. Although this variable was selected arbitrarily, this format was noted to be both machine-readable and visually tidy. For the purpose of this audit, dd/mm/yyyy: was also accepted. Other variations—including formats like d/m, dd/m, or dd/mm (without a separating colon)—were excluded. While the choice of date format is unlikely to impact clinical decision-making, inconsistent formatting may affect the structural flow of documentation, particularly in MMPs with multiple contributors and longitudinal edits.

3.2 Indications and Colour Use in Medication Documentation

Figure 5 illustrates the formatting choices used when documenting clinical indications alongside medications. While some MMPs used a hyphen (e.g., “hydrocortisone – sepsis”), the majority (65%) used parentheses (“hydrocortisone (sepsis)”), suggesting a preference for the latter among pharmacists.

Figure 6 shows the use of coloured text as a visual tool to emphasise key information within MMPs. Coloured formatting was used in 35% of MMPs, typically to highlight the final “Medication Issues” section. Most of these entries used purple text; however, one pharmacist used red, indicating variation in stylistic preferences. While not widespread, this strategy may assist in drawing attention to unresolved actions.

4. Quantitative Metrics

4.1 Word count

Table 1. Word Count Summary by ICU Stay Type
stay_type Number of MMPs Mean Median SD Min Max
long 21 334.2 358 75.3 169 428
medium 14 286.1 263 80.8 171 438
short 5 277.8 293 78.5 150 365

Table 1 present the distribution of word counts across ICU MMPs, stratified by patient stay type (short, medium, and long). As expected, word counts were generally higher in long-stay patients, with a median of 358 words compared to 263 and 293 for medium- and short-stay groups, respectively. The range was broadest in medium-stay MMPs (171–438), suggesting greater variability in documentation. While short-stay MMPs had a lower mean word count (278), the median was comparable to medium stays, reflecting a few denser entries despite the shorter length of stay.

Figure 7 displays word count trends across sequential MMPs for two long-stay patients. Both patients showed a general increase in word count over time, reflecting accumulating clinical complexity or repeated information. A drop-off is observed in later MMPs for Patient 1, while Patient 2 maintained consistently high word counts throughout.

4.2 Use of additional subheadings and Note Frequency

Pharmacists frequently incorporated additional subheadings under or adjacent to the “New Medications” section to enhance clarity and organisation. The most commonly used subheadings included:

  • VTE Prophylaxis (VTEP)
  • Infusions
  • Antimicrobials/Antibiotics
  • Scheduled
  • PRN
  • Unchanged (home medications)

Additional subheadings were also applied based on clinical context or individual documentation style. These included:

  • Micro
  • Inpatient Ceased Medications
  • CRRT
  • Feeding
  • Anti-Seizure Medications

Note Frequency

MMP entries were typically posted on a daily basis during weekdays, reflecting weekday ICU pharmacy service coverage. Weekend documentation was infrequent across most sites, with the exception of VHH, where entries continued due to weekend pharmacist availability.

Discussion

Summary of Key Findings

This audit of ICU MMPs revealed considerable variation in documentation structure, with several recurring patterns. Most MMPs included core clinical information such as presenting complaint (90%) and past medical history (75%), though objective clinical data were only present in a minority of notes (20%). Medication issues were documented in 90% of MMPs; however, only 28% included a distinct subheading for these issues. In most cases, they were embedded within the broader sections HOPC.

Under the New Medications section, 80% of MMPs included additional subheadings to organise medication classes, reflecting an attempt to improve clarity beyond what the standard template supports. Formatting strategies for ceased medications, such as greying out or adding a “ceased dd/mm” notation, were inconsistently applied. Use of colour for emphasis was uncommon (35%), and indications were more frequently documented using parentheses (65%) than hyphens (35%).

In long-stay patients, word count tended to increase over time, with many notes containing repeated content from previous entries. This trend highlights the importance of maintaining structural consistency as documentation lengthens, to support readability and clinical utility.

An additional observation was that the medication issues section—arguably the most clinically relevant part of the MMP—was consistently placed at the end of the note. In longer entries, this positioning often gave it the appearance of a postscript, potentially diminishing its visibility. To address this, some pharmacists highlighted this section using coloured text.

Moreover, as multiple pharmacists contributed entries for a patient over time, noticeable variation in documentation styles emerged. Differences in formatting, phrasing, and overall structure made it challenging to follow the clinical narrative from one entry to the next.

Implications for Practice

The frequent use of additional subheadings under “New Medications” indicates that the current MMP template does not fully support the complexity of ICU prescribing. Pharmacists consistently adapted the structure to better organise key therapy areas, particularly for antimicrobials, infusions, and supportive care.

Inconsistent formatting—such as variations in how ceased medications and dates are recorded—contributes to increased cognitive burden when interpreting longitudinal documentation. As entries accumulate over time, especially in long-stay patients, the lack of a clear distinction between current and historical content makes it more difficult to quickly identify relevant updates.

These findings highlight the value of a more standardised layout to improve clarity, reduce documentation fatigue, and support efficient information retrieval across episodes of care.

Limitations

This audit examined a sample of 40 MMPs from four sites, focusing primarily on medium- and long-stay ICU patients. Consequently, the findings may not capture the full range of ICU pharmacist documentation or apply to shorter admissions with different needs. Additionally, because clinical outcomes and the rationale behind documentation choices were not assessed, interpretations are limited to observable structural elements.

Furthermore, this review was confined to analyzing only the written content of MMPs and did not investigate how clinicians perceive or use these notes in practice. Insight into usability and cognitive workload, from the perspective of pharmacists as well as other healthcare professionals, would add valuable depth to these findings.

Future Directions

A logical next step would be the development of a comprehensive guideline for ICU MMP documentation, structured around four key domains.

Patient Presentation and Issues:
The guideline should define expectations for the inclusion and structure of core clinical content, such as the presenting complaint, past medical history, objective data, and active clinical issues. Establishing a consistent and unified approach would help distinguish clinically useful information from redundant or low-value content, ensuring greater clarity and utility across pharmacist entries.

Medication Reconciliation:
Guidance should be provided on documenting medication-related decisions with clarity and consistency. This includes the structured use of subheadings, grouping of medications by therapeutic category, and a clear distinction between inpatient medication changes and home medication decisions.

Formatting and Visual Aids:
The guideline should promote standardised formatting conventions to enhance readability and reduce ambiguity. Key areas include consistent annotation of ceased medications, uniform date formatting, and the thoughtful use of visual cues—such as colour or brackets—to draw attention to key issues or status changes.

Quantitative Metrics:
To manage documentation length and improve note readability, the guideline should encourage the use of word count thresholds and recommend the removal of resolved items after 48 hours. Emphasis should be placed on documenting clinically significant medications only, as non-essential therapies (e.g. moisturisers, supplements) are typically accessible elsewhere within the EMR, such as in the MAR or Orders tab.

To support implementation, a standardised EMR template could be developed alongside the guideline, reinforcing the structure while still allowing flexibility for clinical complexity.

Beyond standardisation, there is a strong rationale to move ICU pharmacist documentation away from traditional models used on general medical wards. Currently, the MMP often functions as a running record of medication orders already visible in the MAR, which limits its clinical utility in the ICU setting. Unlike general medical wards—where patient complexity is lower and pharmacist documentation is less frequent—the ICU requires a more focused and clinically meaningful approach to recording pharmacist input.

This shift would support clearer, more purposeful documentation that adds value to patient care, particularly in high-acuity environments where timely and structured information is essential.