In one sentence
Ergebnisdokumentation is the form on which a pharmacy records what it measured or collected and what it handed over. It documents an act that was performed, with the person, the time, the staff member and the device, rather than an interpretation of the finding.
Ergebnisdokumentation is the sheet a pharmacy fills in when it has measured something or collected a sample, and it is the only trace the service leaves once the customer has walked out. A value read aloud and remembered is not a record. A number written on the back of a receipt is not a record either, because 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: it asks the same questions in the same order every time, and an empty field is visible to anyone who picks it up.
The content is short and fixed. The identity of the person, in a form the pharmacy could still stand behind months later rather than a first name. The date and the time, since a value without a time is hard to place against a meal, a medicine or a second measurement. The name of the person who performed the act, because a pharmacy has to be able to say who stood there. The device or the laboratory used, identified by instrument or by request number, so the measurement can be traced back to a system that was under control that day. Then the substance of it, either the value the device produced or the plain fact that a sample was taken and sent. Finally, what the customer was actually told.
That last field is the one most often left blank and the one that carries the most weight. 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. A number sitting outside a Referenzbereich is a reason to refer and nothing more, and 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. 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 billing and defence rest on the same sheet. Once it is signed it becomes patient documentation and falls under the Aufbewahrungsfristen for health records, which are longer than the periods a retail business is used to.
This glossary entry is general information about German pharmacy law and practice. It is not legal advice. For binding guidance on your own pharmacy, contact your Landesapothekerkammer.
