2. Pharmacist Work-up of Drug Therapy
• Pharmaceutical care, is a systematic method for recording the
pharmacist’s examination of a patient pharmacotherapy and
subsequent identification of medication-related problems
• The pharmaceutical care plan process (CORE, PRIME & FARM/ SOAP),
is a useful and required documentation tool for pharmacists, as it
facilitates continuity of care for patient.
• The pharmacist must use his or her discretion to decide what
information should be communicated.
3. CORE PHARMACOTHERAPY PLAN
1. Data collection
Demographic data (Age, sex, race)
Patient data(Family history, Medical, Dietary, Medication, Physical
findings, Lab investigations, patient complaints, signs and symptoms).
2. Develop or identify the CORE pharmacotherapy plan
C = Condition of the patient
O = Outcomes desired in the specific patient
(POEMS) : Patient oriented outcomes that matters (Mortality,
Morbidity, Behavior, Economic, Quality of life).
Therapeutic end point
4. CORE PHARMACOTHERAPY PLAN
R = Regimen selected to achieve the desired outcome
1. Therapeutic regimen
Existing therapy: Pharmacist is asked to work with a patient with one
or more agents. Evaluate the current regimen for its potential to
achieve the outcome.
• Initial therapy: List the therapeutic options (drugs & regimen) most
likely to achieve the desired end points; Select the option best suited
for the patient’s medical, physical, psychological, mental and financial
well-being.
5. CORE PHARMACOTHERAPY PLAN
2. Goal setting and Behavior regimens.
• Identify type of goal : Start, increase, stop/decrease, continue
E = Evaluation of parameters to assess outcome
1. Efficacy parameters: What should be monitored, how often?
2. Toxicity parameters: Adverse reactions, allergic reactions and
toxicity.
6. PRIME PHARMACOTHERAPY PLAN
• P = Pharmaceutical-based problems: Patient not receiving prescribed
drug, devices. Routine monitoring missing.
• R = Risks to patient: Adverse drug reactions/drug allergy.
• I = Interactions: Drug-drug, drug-disease, drug-food, drug-lab
interaction.
• M = Mismatch between medications and conditions or patient needs:
No Indication for the current drug, device; Indication for a drug,
device or intervention but none prescribed; Barriers to
implementation of medication.
• E = Efficacy Issues: Too much of the correct drug, Too little of the
correct drug, Wrong drug, device, intervention, or regimen prescribed
or more efficacious choice possible.
7. Documentation of Pharmaceutical care
• FARM NOTE : For documenting interventions intended or provided by
the pharmacist.
• F = Findings
• A = Assessment
• R = Resolution
• M = Monitoring and follow-up
• Finding (F) : Patient specific information that gives a basis for, or leads
to, the recognition of pharmacotherapy problem or indication for
pharmacist intervention. Within FARM notes findings include both
subjective and objective findings.
8. Documentation of Pharmaceutical care
• Assessment (A)
E.g. : Short term goal:
• Eliminate symptoms, Lower blood pressure to a target within six
weeks, Manage acute asthma exacerbation without hospitalization.
E.g. : Long term goals:
• Prevent recurrence of the condition (MI), Maintain BP, Prevent
progression of diabetic neuropathy.
9. Documentation of Pharmaceutical care
• Resolution (R) : Includes prevention, recommendations of other
health care professionals.
• Rationale for choosing a specific intervention should be stated.
Interventions are:
1. Observing, reassessing or following
2. Counseling or educating the patient or caregiver
3. Informing the prescriber
4. Making recommendations to the prescriber
5. Withholding medication or advising against use
10. Documentation of Pharmaceutical care
• Monitoring (M) : Monitoring and follow-up of parameters and timing
of follow-up, to assess the efficacy, safety and outcome of
intervention.
• The parameter to be followed (Pain, depressed mood, serum
potassium level).
• The intent of the monitoring (Efficacy, toxicity, adverse event)
• How the parameter will be monitored (Patient interview, serum drug
level, physical examination)
• Frequency of monitoring (weekly, monthly)
• Duration of monitoring (until resolved)
• Decision point to alter therapy when or if outcome is not achieved.
11. SOAP NOTE
• A SOAP note is one documentation format that is commonly used for
documenting in-patient charts, in the institutional setting.
• It uses the problem-oriented approach to documentation, where
S = Subjective information
O = Objective patient information
A = Assessment of the problem (i.e., your Thought Process)
P = plan of how the problem will be addressed and when follow-up
will occur.
12. SOAP NOTE
• The following provides an example of a SOAP note using Patient
Walsh as an example.
• S: Mrs. Walsh has been concerned about developing osteoporosis.
She has never taken calcium supplements. She does not like to take
milk products, although she does take a multiple vitamin that
provides her with vitamin D 400IU. She does not have a family history
of osteoporosis and has an active lifestyle, which consists of
gardening and golfing in the summer, and two miles every day in the
winter. She has never discussed osteoporosis with her physician, has
never had a bone density done and has never been on hormone
replacement therapy.
• O: She is a 65 years old female of small build. She is not on any
medications that can increase her risk of osteoporosis
13. SOAP NOTE
• The following provides an example of a SOAP note using Patient
Walsh as an example.
• S: Mrs. Walsh has been concerned about developing osteoporosis.
She has never taken calcium supplements. She does not like to take
milk products, although she does take a multiple vitamin that
provides her with vitamin D 400IU. She does not have a family history
of osteoporosis and has an active lifestyle, which consists of
gardening and golfing in the summer, and two miles every day in the
winter. She has never discussed osteoporosis with her physician, has
never had a bone density done and has never been on hormone
replacement therapy.
• O: She is a 65 years old female of small build. She is not on any
medications that can increase her risk of osteoporosis
14. SOAP NOTE
• A: Mrs. Walsh’s calcium intake is significantly lower than what is suggested
by the guidelines for prevention of osteoporosis (1.5g per day). This puts
her at an increased risk of developing osteoporosis, and she wo
• P: 1. Calcium carbonate 600mg twice daily (breakfast & supper)
• 2. Provide a sheet summarizing calcium content of various foods. If Mrs.
Walsh diet should change to include these food groups, her dose of calcium
should be adjusted.
• 3. Provide a pamphlet discussing osteoporosis
• 4. Have Mrs. Walsh make an appointment for tomorrow to: 1) discuss
osteoporosis and, if necessary, refer her to her physician for further
evaluation. Recommend that she continue with her exercise programe.
15. SCOPE AND APPLICATIONS
• Pharmaceutical care plan is designed to promote health, prevent
disease and to ensure that drug therapy regimens are safe and
effective.
• Pharmaceutical care activities have been shown to improve the
quality and cost-effectiveness of health care.
• Pharmacists assess therapeutic need, prevent or manage adverse
drug reactions, develop patient-specific management plans, manage
chronic disease and monitor outcomes.
• By conducting medication management, the pharmaceutical
professionals are the primary facilitators for the appropriate use of
medication, thereby limiting unintentional harm due to medication.
16. SCOPE AND APPLICATIONS
• Pharmaceutical care is a philosophy of practice in which the individual
is the primary beneficiary of the pharmaceutical professional's
actions.
• The digital pharmaceutical care enhanced the responsible
pharmaceutical care to achieve outcomes that positively affect a
person's quality of life.
• The optimal pharmaceutical care is supported by a personal health
record that can help a person or the person's representative maintain
and manage all of the individual's health-related data in a private and
secure environment.
17. Enhancing Quality of Patient-Centered Care Services
• PC implementation is a necessity today. The role of pharmacists in
patient-centered care is needed and demanding. Pharmacists are
required to implement patient-centered care.
• The presence of pharmacists in a healthcare team has been proven to
help facilitate access to primary care and improve patient outcomes.
• Medication management is an important and complex aspect of
chronic disease management. The pharmacist is responsible
for ensuring that your drug therapy is optimal and safe, and for
providing you with all relevant information
18. SCOPE AND APPLICATIONS
• The basic duty of a pharmacist is to check prescriptions from
physicians before dispensing the medication to the patients to ensure
that the patients don't receive the wrong drugs or take an incorrect
dose of medicine.
• PC plan involves three major functions: identifying potential and
actual drug-related problems, resolving actual drug-related problems
and preventing drug-related problems.
• Pharmacists can help in managing chronic disease conditions by
providing clinical services and drug information to patients and other
healthcare providers and by acting as a consultant for treatment-
related issues.
19. SCOPE AND APPLICATIONS
• Pharmaceutical care is a concept that deals with the way, people
should receive and use medication and should receive instructions for
the use of medicines. It also deals with responsibilities, medication
surveillance, counselling and outcomes of care.
• The provision of pharmaceutical care by pharmacists
involves identifying, resolving, and preventing drug-related problems.
Many medication errors, adverse drug reactions, drug interactions,
and inappropriate therapies can be avoided, which will certainly
benefit the patient as well as the other health care professions.
