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Pharmacy Services
Pharmacy First: A Guide to Accurate Clinical Documentation
What to record, when to record it, and why accurate PharmOutcomes documentation is the foundation of a safe and compliant Pharmacy First service.
About this service
Pharmacy First gives community pharmacists the authority to assess patients and supply prescription-only medicines without a general practitioner (GP) referral. That authority rests entirely on Patient Group Directions (PGDs): legal frameworks that permit supply only when strict criteria are met and fully documented. If the documentation is incomplete or inaccurate, the supply may be unlawful regardless of the clinical decision.
Accurate documentation also matters for the quality of care. A record that captures the full clinical assessment allows any pharmacist reviewing the patient later to understand what was found, what was supplied, and what safety netting was given. Poor records mean poor continuity.
This article covers what must be recorded for every Pharmacy First consultation, why each element matters, and the documentation errors that most commonly lead to failed audits, rejected claims, or patient safety incidents.
Who to offer the service to
Include
- All Pharmacy First consultations regardless of outcome (supply, delayed supply, self-care, or referral)
- Clinical records should be completed contemporaneously during or immediately following the consultation
- Documentation applies whether or not an antibiotic or other medicine is supplied
Exclude
- There are no exclusions: every Pharmacy First consultation requires a complete record
How to deliver the service
- Open the consultation record at the start Open PharmOutcomes (or the NHS-approved equivalent) before or at the start of the consultation to support contemporaneous documentation. Aim to complete and finalise the record as soon as practicable after the consultation. Records created hours or days later from memory are less accurate and carry greater audit risk.
- Record the clinical assessment as you go For conditions using a scoring tool (for example FeverPAIN for sore throat), record each component as you assess it, not just the final total. For conditions requiring visual assessment (for example impetigo or infected insect bite), describe findings specifically -- "spreading erythema approximately 5cm x 3cm on left forearm with warmth and tenderness" is far more useful than "redness noted".
- Maintain patient-centred consultation skills Real-time documentation should support, not replace, effective communication. Avoid focusing solely on the screen or entering data continuously while the patient is speaking. Use active listening, maintain appropriate eye contact, and allow the patient to explain their symptoms in their own words before documenting detailed responses. Patients may not always describe symptoms clearly or volunteer important information immediately: pausing data entry to explore concerns and clarify responses often improves both the quality of the clinical assessment and the accuracy of the final record. The consultation should be led by the patient interaction, with documentation used to support safe and complete record keeping.
- Confirm and record eligibility explicitly Do not assume eligibility is implied by the supply decision. Every record should include a clear statement that inclusion criteria were met and exclusion criteria were checked. For conditions with complex eligibility (for example UTI in women, where pregnancy must be ruled out), record how each exclusion was assessed.
- Record the supply decision and rationale State which PGD criteria support the supply. For antibiotic supplies, record the specific antibiotic, dose, frequency, duration, quantity, batch number, and expiry date. For delayed supplies, record that a backup prescription was issued and the specific instructions given to the patient about when to use it.
- Document safety netting in specific terms Vague safety netting documentation is one of the most common audit failures. "Advised to seek help if needed" does not meet the standard. Record the specific symptoms the patient was told to watch for, the timeframe, and what to do (return to pharmacy, call NHS 111, attend the emergency department, or call 999). For antibiotics, also record that the patient was told to complete the full course and what to expect in terms of side effects.
- Finalise and submit the claim The clinical record must be completed contemporaneously. Submit the claim as soon as practicable after the consultation. Delayed documentation increases audit risk and may result in an incomplete record. Ensure the record is finalised before moving on to the next consultation.
Consultation outcome: what to record
| Result | Action | Urgency |
|---|---|---|
| Self-care only (no supply) | Record: eligibility assessment, clinical score or findings, rationale for no supply, self-care advice given, specific safety netting provided. | Full record required |
| Delayed (backup) supply | Record: all fields as above, plus antibiotic details (name, dose, quantity, batch, expiry), and specific instructions given to patient about when and how to use the delayed prescription. | Full record required |
| Immediate supply | Record: all fields as above, plus allergy confirmation, antibiotic details (name, strength, dose, frequency, duration, quantity, batch number, expiry), and counselling given. | Full record required |
| Referral (no supply) | Record: assessment findings, reason for referral, where the patient was referred (GP, NHS 111, emergency department, or 999), and any interim advice given. | Full record required |
Documentation Requirements for Every Pharmacy First Consultation
The following information should be recorded for every Pharmacy First consultation. It includes information required by the Pharmacy First service specification, the relevant Patient Group Direction (PGD), and good clinical record-keeping practice.
| Field | What to record | Why it matters |
|---|---|---|
| Patient identifiers | Full name, date of birth, NHS number | Links the record to the correct patient. Required for any clinical communication and for audit. |
| Presenting complaint | Chief symptom, duration in days, and any relevant associated symptoms | Establishes the clinical context and confirms the presenting condition falls within the Pharmacy First pathway. |
| Eligibility confirmed | Confirmation that inclusion criteria are met and exclusion criteria are absent, with any relevant details noted | Demonstrates that the PGD criteria were applied. Without this, the supply cannot be shown to be lawful. |
| Clinical assessment score | All individual scoring components and the total (e.g. each of the five FeverPAIN criteria for sore throat) | Recording only the total score is insufficient. Audits require the individual components to verify scoring was applied correctly. |
| Supply decision | Whether self-care, delayed supply, or immediate supply was provided, with brief rationale | Connects the clinical assessment to the outcome. Required to show the PGD supply criteria were met. |
| Medicine supplied | Name, strength, dose, frequency, duration, quantity, batch number, and expiry date | All fields are required for a valid PGD record. Batch number and expiry date are legal requirements for any PGD supply. |
| Allergy status | Penicillin allergy (and any other relevant allergy) confirmed or ruled out | Failure to record allergy status is one of the most common audit failures and a direct patient safety risk. |
| Advice given | Self-care measures discussed and any written information provided | Demonstrates the pharmacist fulfilled the counselling duty of the PGD. |
| Safety netting | Specific symptoms the patient was told to watch for, and what action to take | The single most important patient safety element. Must be specific -- "seek urgent help if symptoms worsen" is not sufficient on its own. |
| Referral | Where the patient was referred and why, if applicable | Required if the consultation ended in referral rather than supply. Establishes that appropriate action was taken when the PGD criteria were not met. |
Condition-Specific Documentation Requirements
In addition to the universal fields above, each Pharmacy First condition has specific documentation requirements.
| Condition | Specific requirement |
|---|---|
| Acute sore throat | All five FeverPAIN component scores recorded individually (F, E, V, E, R) plus the total. Penicillin allergy confirmed before any antibiotic supply. |
| Sinusitis | Duration of symptoms confirmed and documented (at least 10 days, or worsening after initial improvement). Antibiotic supply rationale documented. |
| Acute otitis media | Age confirmed (1-17 years). Relevant ear examination findings recorded. Penicillin allergy status confirmed. |
| Infected insect bite | Signs of cellulitis documented (spreading redness, warmth, swelling). Any signs of systemic infection or anaphylaxis noted or ruled out. |
| Impetigo | Lesion distribution and extent documented. Distinction between non-bullous and bullous impetigo noted where relevant. |
| Shingles | Age confirmed (18 and over for antiviral supply). Rash onset and site documented. Ophthalmic involvement ruled out or referred. |
| UTI in women | Age confirmed (16-64 years). Pregnancy ruled out and documented. Upper urinary tract infection (pyelonephritis) symptoms ruled out. Catheter status noted. |
Recording and submission
- Use PharmOutcomes (or the NHS England approved equivalent) for all Pharmacy First records. Records must not be kept only on paper or on a non-approved system.
- Timing:
- Open the consultation record before or at the start of the consultation
- Complete the clinical record contemporaneously during or immediately following the consultation
- Finalise and submit the claim as soon as practicable after the consultation
- Delayed documentation increases audit risk and may result in incomplete records
- Audit and compliance:
- NHS England and Local Pharmaceutical Committees (LPCs) may audit Pharmacy First records at any time
- Inadequate documentation may make it difficult to demonstrate that PGD requirements were met and may lead to claim rejection or regulatory concerns during audit
- Incomplete records are the most common reason for audit failure
- Retain records in accordance with current NHS records management requirements and local information governance policies
⚠ Common service pitfalls
- Recording only the FeverPAIN total without the individual components. The audit standard requires all five components to be documented separately. A total of "4" does not show which criteria were present.
- Vague safety netting. "Told to seek help if needed" fails the audit standard. Safety netting must name the specific symptoms to watch for and the specific action to take (return, 111, emergency department, or 999).
- Not recording allergy status. Missing allergy documentation is one of the most consistently cited failures in Pharmacy First audits. Penicillin allergy must be confirmed and recorded for every antibiotic supply.
- Omitting batch number and expiry date. These are legal requirements for any PGD supply. Dispensing labels alone do not satisfy the documentation requirement -- they must appear in the PharmOutcomes record.
- Assuming a supply decision documents itself. The record must explicitly state that the PGD criteria were met -- not just that an antibiotic was supplied. Auditors look for the reasoning, not just the outcome.
- Documenting after the patient has left from memory. Retrospective documentation is less accurate, harder to defend, and may not meet the PharmOutcomes submission window. Build the record in real time.
- Using the wrong condition pathway in PharmOutcomes. Selecting the wrong condition in the system means the record is associated with the wrong PGD criteria, which can invalidate the claim entirely.
- Not recording referrals. If a patient is referred, this must be documented even though no medicine was supplied. A missing referral record suggests the consultation was not completed appropriately.
- Allowing the consultation to become a checklist exercise. Clinical tools and PharmOutcomes prompts support decision-making but do not replace professional judgement, active listening, or exploration of the patient's concerns.
Key takeaways
- Every Pharmacy First consultation requires a complete record in PharmOutcomes -- including consultations that end in self-care advice or referral with no supply.
- Record clinical assessment components individually as you go, not from memory after the patient leaves -- incomplete or retrospective records are the leading cause of audit failure and claim rejection.
- Safety netting documentation must name the specific symptoms to watch for and the specific action to take: vague wording does not meet the audit standard and leaves a gap in patient safety.
Download the checklist
Professional disclaimer: This article is for educational purposes
to support healthcare professionals' clinical decision-making. It does not replace
independent professional judgement, local pathways, NICE guidance, or standard
medical literature. Members of the public must not use this resource for
self-diagnosis and should seek prompt advice from a qualified healthcare
professional if experiencing chest pain, palpitations, fainting, or breathlessness.