Documentation of pharmaceutical care

Documentation of pharmaceutical care NO DOCUMENTATION MEANS YOU DID NOT DO IT!!

Documentation of pharmaceutical care Definition Effective recording for all decision made concerning the patient drug therapy and outcome

Documentation of pharmaceutical care Aim It is required to facilitate the collaboration among the health care providers. Provide quality patient care Manage the practice Legal issues Evaluate performance Justify professional role Reimbursement

Development of a Efficient Patient Record The problem-oriented pharmacy record Patient name Patient’s clinical information. Medication list Medical problem list Allergies Drug-related problem list Problem-oriented notes Goal of therapy Effectiveness and safety of medication at the follow-up.

Development of a Efficient Patient Record The problem-oriented pharmacy record Standard format – date – note label – note – signature

FARM note The FARM note, serves as a part of the patient's pharmacy database.

FARM note F = Findings: - Patient – specific information which leads to recognition of pharmacotherapy problems. In FARM note, findings include both subjective and objective information.

FARM note A = Assessment: The pharmacist's evaluation of findings, including a statement of: - Any additional information that is needed to best assess the problem to make recommendation. - The severity, priority or urgency of the problem. - The short term and long term goals of the intervention proposed or provided. E.g. of short term goals: Eliminate symptoms, lower blood pressure to 140 / 90 mm Hg within 6 weeks or manage acute asthma without requiring hospitalization. E.g. of long term goals include: Prevent recurrence, maintain BP at less than 130 / 80 mm Hg, prevent progression of diabetic nerve disease.

FARM note R = Resolution (including prevention): - Include actual or proposed actions by the pharmacist or recommendation to the other health care professionals. It may include: - Observing, following: No intervention necessary at this time, if no action was taken or recommended. - Informing the prescriber and make recommendation for him. Withholding medication or advising against use. Counseling or educating the patient or caregiver.

FARM note M = Monitoring and follow up: It may include: - The parameters and timing of follow up monitoring to assess efficacy, safety and outcome of the intervention. It may include: The parameter to be followed (e.g. pain, depressed mood, K level in serum) The intent of monitoring (e.g. efficacy, toxicity, adverse effects) How the parameter will be monitored ( e.g patient interview , physical examination , serum drug level ) Frequency of monitoring ( e.g weekly , monthly ) Duration of monitoring Desired findings ( e.g no pain , euglycemia , healing of lesions) Decision point to alter therapy if outcome not achieved (e,g pain still present after 3 days , mild hypoglycemia more than 2 times a week )

SOAP note S = subjective findings - Patient – subjective information which leads to recognition of pharmacotherapy problems Subjective data are open to individual interpretation and patient’s own words, what the patient tells me or what is known from history) --- (Chief Complaint) - reason for visit, symptoms, duration , severity of symptoms past treatments …. Some times we can't differentiate between objective data from subjective data , in this case they combined as a single section " S/O findings”

SOAP note O = objective findings :- Patient – specific objective information which leads to recognition of pharmacotherapy problems Physical examination, laboratory results, diagnostic tests, pill counts. Measurable data: e.g lab data , weight , height , blood pressure and pulse)

SOAP note A = Assessment As farm note, we use objective and subjective data. Brief and complete description of problem and diagnosis Any additional information that is needed to best assess the problem to make recommendation. The severity, priority or urgency of the problem. The short term and long term goals of the intervention proposed or provided.

SOAP note P = plan The plan is usually expanded to describe information included in the monitoring / follow up section in the FARM format. Detailed description of further workup, treatment, education, monitoring and follow-up relative to assessment Laboratory or prescriptive authority achieved under collaboration protocol with specific physician (s), or within a specific health care facility or system.

SOAP note P = plan 3 steps / components – Establish goals (parameter, value & timeframe) • Outcome is what actually happens – Individualized interventions • Change medication regimen, patient education… – Time frame and measures for evaluation

SOAP note HCP: health care provider

SOAP and FARM

Some tips Keep your note SHORT and TO THE POINT Most initial notes usually ≤ 1 page Follow-up notes usually shorter than initial notes Don’t include information that does not assist in decision making

What s wrong with the following? Mrs. RG is a 76 yr-old woman with 5 grandchildren. She comes into the pharmacy requesting OTC treatment for a history of osteoarthritis x 2yrs. She claims a history of aspirin allergy (GI upset). PMH includes OA, GERD, BP and elevated TC

What s wrong with the following? Includes irrelevant information – 5 grandchildren

What s wrong with the following? Medication history includes - Norvasc 10 mg qd for BP - Nexium 20 mg qhs for GERD - Pravachol 20 mg qd for elevated TC. Cholesterol 165 mg/dl

What s wrong with the following? History is incomplete - includes only prescription medications filled in this pharmacy

What s wrong with the following? Dose of APAP too low for OA. Patient requires symptomatic pain relief for OA pain. Has tried Tylenol 500 mg tid in past with little relief

What s wrong with the following? Introduces new information in the Assessment that should be in S or O -use of Tylenol - Has tried Tylenol 500 mg tid in past with little relief

What s wrong with the following? P Recommended pt increase APAP to 1 g po qid. Patient agrees

What s wrong with the following? P Wrong Missing follow-up and monitoring plan.