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Current Content Expert: Kevin W. Chamberlin, PharmD Assistant Clinical Professor University of Connecticut School of Pharmacy & UConn Center on Aging Legacy Content Experts H.E. Davidson, PharmD, MPH Partner, and Assistant Professor of Internal Medicine Insight Therapeutics, and Eastern Virginia Medical School, Norfolk, VA Barry Rumble, RPh Director of Consulting Services Riverside Regional Convalescent Center
Course Objectives: At the conclusion of this application based activity, the participant will be able to: Assess the basic elements of therapeutic care planning. Specify the steps and principles in designing a therapeutic regimen, explaining the purpose and contents of the medication regimen and the anticipated outcomes of the data assessment process.
Determining health care problems Defining health care needs Identifying patient needs
Identify Goals:
Design the Therapeutic Regimen Monitor the Patient Document Patient Progress Therapeutic care planning involves defining a patients health care needs based on actual and potential health care problems. By accurately identifying these problems, relevant health care needs arise. It is from these needs that pharmacological and other therapeutic goals are established, and a therapeutic regimen is designed, implemented, and monitored. Therapeutic care planning focuses on the whole patient in order to: A. Identify as many opportunities for pharmacological intervention as possible B. Ensure patient compliance with the therapeutic regimen C. Treat possible psychological barriers to success of the therapeutic care plan D. All of the above
CORRECT ANSWER: B. Therapeutic care planning takes into account physical, psychological, and any other barriers thay may prevent the patient from maintaining compliance with the recommended therapeutic regimen.
Patient demographics Medical, social and family history Medications and related products Patient complaints, signs, and symptoms
In order to identify a pharmacotherapeutic need, you must look to the underlying problem and collect data to gain the most complete picture possible. These data must provide clues to actual or potential health care problems. Data on patient characteristics, medication history, other substances being used, presenting complaints, and signs and symptoms should be gathered during this part of the care planning process. 03.01.03 Identifying Problems: Patient Demographics, Social and Medical History
Demographic Data
o o o o o
past health problems past surgeries, treatments, etc. current health status physical, nutritional, cognitive
Data on patient demographics, such as age, gender, ethnicity, race, and religious preferences should be collected. The patients family, social and medical histories are also relevant. Current health status considers the patients nutritional, functional, and cognitive status, as well as other patient-specific issues.
how and when drugs are/were taken allergies and drug reactions toxicity profile of drug
Drug administration technique (e.g., PO, IV, PEG) Other products consumed (e.g., smoking, alcohol, caffeine) Patients beliefs in therapy Compliance
o o
Information on concurrent medications is critical in order to identify actual or potential health care problems. Both past and present medication histories should be considered in regards to how and when the drugs were taken, allergies noted, and the toxicity profile of the drug. Drug-drug interactions, drug-food interactions, and duplicative medicines should be identified and screened. The technique for administering the drug should be noted and compliance assessed through reviews of the medication administration record and refill records. Information on other products consumed such as caffeine, alcohol, smoking and homeopathic remedies should also be gathered at this time.
Impairments
The patients complaints, signs, and symptoms should be described and assessed for severity and duration. Impairments and disabilities should be noted along with the patients perception of the disease. Remember that subjective and objective both may influence the identified need and potential solution.
patient physician physician extenders (nurse practitioners / physician assistants) other caregivers (e.g., nurses aids, nurses, other ancillary staff) family
Records:
Medical Professionals:
In order to confirm the medical problem, the pharmacist should collect patient data from a variety of sources including the patient, physician, other caregivers or family members. Medical records, pharmacy profiles, and laboratory reports can help uncover quantifiable data. Observations of medical professionals such as
physicians, nurses and other long-term care facility staff can reinforce qualitative data findings.
After collecting the various data and identifying the problem or problems, the health care needs should become evident. Two considerations must be kept in mind when identifying needs: the ability to resolve current problems and the ability to avoid potential future problems.
Focus must be on whole person Individual needs must be taken into account Patients must have:
o o o o
an understanding of their illness an understanding of their drug therapy realistic expectations their concerns addressed
The care process is driven by patient needs and preferences; therefore, the care plan must take the whole person approach, rather than focus solely on the pharmacotherapy that addresses an illness. The patients individual needs must be considered at the onset of care planning, because cooperation and compliance are essential to the success of the plan. Compliance depends on patients having a basic understanding of their illness and how their actions can affect the condition. Patients also need to have an understanding of their drug therapy, so that they can help monitor their progress, and report any unexpected effects that may arise. Working with the patient to set realistic therapeutic expectations is important, as is addressing any concerns they may have about the condition and treatment. Side effects, allergies, and costs are common concerns of the elderly undergoing treatment.
For the elderly in long-term care facilities, many of these issues will not apply. Due to the high prevalence of cognitive and functional impairment in this population, many of these issues will be addressed through caregiver discussions or directed by regulatory guidelines. Frequently, the resident will be unable to express clinical outcome of drug therapy. 03.01.10 Characteristics of Therapeutic Goals
measurable observable specific attainable over a definite time period addresses the gap between where patient is and where patient should be
The ultimate goal of care is to improve a patients quality of life through reaching defined or predefined medication-related outcomes that address a need. Therapeutic goals must be measurable and observable. The more specific the goal, the greater ability to measure the goal. All goals should have definitive and realistic time frames in which to attain them. Understanding where patients are in terms of their health status and where you would like them to be is the first step in determining goals for a given condition.
The patient can help establish quality of life goals Patient involvement must be monitored The patients family may play a key role in setting goals and achieving therapeutic outcomes To be effective, care must be provided directly to the patient, and require his or her participation. Patients who are involved in establishing quality of life goals for their therapy are more likely to reach them. However, this involvement must be monitored to ensure that the patient does not interfere with the reaching the desired therapeutic outcomes. For
example, the patients administration of medication must be periodically checked to make sure that he or she is taking the correct dosages. Elderly patients who are cognitively or functionally impaired may not be able to become directly involved in their own care. Family intervention is a major consideration in setting goals and meeting therapeutic outcomes for these patients.
03.01.12 Establishing Therapeutic Goals: Roles of the Pharmacist and Other Caregivers
The pharmacist and other medical professionals must provide education as to how to best achieve therapeutic goals The roles of the patient, family, pharmacist, and other caregivers must be considered when planning and providing patient care
While patients have a responsibility to help achieve desired outcomes, the pharmacist and other medical professionals are responsible for educating caregivers and patients about behaviors that will help patients reach their therapeutic goals. The roles and responsibilities of the patient, family, pharmacist and other caregivers must all be considered when defining goals and providing care.
advance directives potential to achieve desired outcomes potential risks patient or family preferences
The decision to avoid pharmacotherapy is a valid care option for some patients based on advance directives, the ability to achieve desired therapeutic outcomes, potential risks, and patient or family preferences. If pharmacotherapy is used, the pharmacist must consider other medication-related factors that affect therapeutic goals. These factors include the nature of the medication selected, the dosage, routes of administration, the drugs safety profile, monitoring and counseling considerations, and quality of life issues.
problem characteristics health care needs patient/family needs and preferences therapeutic goals
what problems will be addressed what problems will be the responsibility of the pharmacist what goals will be addressed first
In order to determine pharmaceutical goals, the pharmacist must integrate the problem characteristics, the health care needs and preferences of the patient and family, and the therapeutic goals established by health professionals and caregivers involved in the case. These pharmaceutical goals are then prioritized by clearly identifying what problems will be addressed, what problems will be the responsibility of the pharmacist, and what goals will be addressed first. As with all therapeutic goals, each pharmaceutical goal should be measurable and associated with a specific time frame for achievement.
Focus on meeting the patients health care needs, not just resolving drug therapy problems Consider therapeutic goals of other health care providers and their impact on pharmacotherapy Remember that therapeutic goals change as the patients health status and needs change
When identifying pharmaceutical goals, one should keep in mind that such goals are definite or predefined, and related to therapeutic outcomes. Pharmacists must focus on meeting the patients health care needs, not simply resolving drug therapy problems. The therapeutic goals of other health professionals on the team must be considered, as well as the impact of these goals on pharmacotherapy. Remember that therapeutic goals and the medication regimen will require updates as the patients status changes.
03.01.16 Resources For additional information, see: Adamcik, B. A. & Rhodes, R. S. (1993). The pharmacist's role in rational drug therapy of the aged. Drugs Aging; 3(6): 481-486. Anderson, R. J. & Miller, S. W. (1992). Geriatric drug therapy. In: Herfindel, E. T., Gourley, D. R. & Hart L. L., (Eds.). Clinical Pharmacy and Therapeutics, 5th ed. Baltimore: Williams & Wilkins, 1489-1507. Cipolle, R.J., Strand, L.M. & Morley P.C. (1998). Pharmaceutical Care Practice. New York: McGraw Hill. updated 2nd edition available ( 2004). Faden, R. & German, P. S. (1994). Quality of life. considerations in geriatrics. Clin Geriatr Med; 10(3): 541-51. Feinberg, J. L. (1991). Taking responsibility for therapeutic outcomes:barriers to consultant pharmacists. Consult Pharm; 6(12): 958-965. McKenzie, L. C., Kimberlin, C. L., Berardo, D. H., Pendergast, J. F. (1991). Pharmacists care of elderly patients. University of Florida, College of Pharmacy.
Torg, E. (1992). Life since OBRA: roles and responsibilities of consultant pharmacists and physicians in long-term care. Consult Pharm; 7(12): 12821290. Wong, B. J., et al. (1994). Role of the pharmacist on a geriatric assessment team. Consult Pharm; 9(10): 1149-1158. Websites: American Society of Health-System Pharmacists http://www.ashp.org American Society of Consultant Pharmacists http://www.ascp.com American Pharmacists Association http://www.aphanet.org/ Agency for Healthcare Research and Quality http://www.ahrq.gov/
03.02.01 Steps in Designing a Therapeutic Regimen Define Needs Identify Goals Design the Therapeutic Regimen:
drug selection simplify regimen dosing written directions and product information
After determining the medical problem, health care needs and therapeutic and pharmacologic goals, a therapeutic regimen may be designed. Designing a therapeutic regimen involves selecting the appropriate interventions, explaining the regimen to the patient and family and considering factors that influence noncompliance. Strategies for avoiding adverse drug reactions are also considered at this time. 03.02.02 Principles for Designing a Therapeutic Regimen
overall health concomitant disease concurrent medications drug therapy problems Is the problem caused by medication? Should the problem be treated by medication?
Consider medical risks and potential toxicity Identify and evaluate therapeutic alternatives
The therapeutic regimen must be individualized to the needs of the patient. The pharmacist must consider individual patient characteristics such as overall health, concomitant disease, and concurrent drug therapy problems. Each health care problem needs to be considered with regard to whether the problem is caused by a medication or needs to be treated with one. Medical risks and potential medication toxicity must also be considered. Therapeutic alternatives should be identified and evaluated for potential inclusion in the pharmaceutical care plan.
Efficacy and effectiveness Safety Contraindications Real and potential drug-related problems
o o
Formulary of approved medications Approved uses of the selected medication Legislative guidelines (e.g., OBRA, other CMS regulations)
In selecting a proper medication and regimen, the pharmacist must consider the drugs efficacy, safety, contraindications, real and potential drug interactions, and any patient characteristics that might affect treatment. In most instances, the selection of an appropriate medication must take into consideration the formulary of approved medications within the health care system, approved uses of the selected medication for specific patient conditions, and regulations such as the Omnibus Budget Reconciliation Act and guidelines from CMS regarding medication use in nursing facilities.
Type of Administration:
oral nasogastric/gastrostomy
topical injectable
Dosing:
pharmacokinetic issues (e.g., renal and hepatic function) concomitant medications patient factors (e.g., age, weight)
Once an appropriate medication is selected, the pharmacist must determine the proper administration of the drug. The frequency of administration is generally related to the pharmacokinetic properties of the medication. Drug half-life and duration of action allow for many medications to be administered once daily, which will save nursing time and allow for increased patient compliance in most cases. While sustained release preparations allow for decreased administration frequency and are usually preferred, elderly patients receiving nutrition through nasogastric or gastrostomy tubes cannot receive these medications. Liquid medications that do not need to be crushed beforehand are usually preferred for these patients when they are available. Patient-specific pharmacokinetic issues need to be considered, such as impaired renal function. Dosage adjustments for renally administered drugs must often be considered for elderly patients. Concomitant medications that interact with the selected medication may need to be eliminated. They may be continued with a dosage reduction in some cases, and require follow-up monitoring for toxicity and effectiveness.
consider special needs of older adults avoid packaging that is difficult to open use matte, not glossy use large boldfaced type must be clear and concise state generic or brand name
Labels:
display special storage considerations include purpose of medication, dosage schedule, side effects
For the geriatric patient, who is functionally and cognitively able to participate in his or her own treatment regimen, several issues need to be considered to ensure compliance. One of these issues is the selection of appropriate containers. Childproof lids and blister packs tend to be difficult to open for elderly patients with limited manual dexterity. Another issue is how critical information about the medication is communicated. Directions for use and product information must be clear and concise. Medication containers should be labeled with large boldface type for easier reading. Matted labels are preferred over glossy labels. Special storage considerations, such as refrigeration, must be prominently displayed. The generic or brand name of the drug, its purpose, thedosing and potential side effects should be included on the label if possible. In institutional environments such as long term care facilities, these issues are more important to those individuals who are administering the medication. Selected elements may be important to communicate in the rare instance when patient self-administration is allowed.
Speak slowly, directly and distinctly Limit comments to essential points Invite questions after each point Use examples and demonstrations Help the patient understand illness, drug regimen, and goals Use education, memory and compliance aids
o o o o o
heart-shaped sticker for cardiovascular medications weekly pill reminder electronic pill boxes vial cap drug diary or calendar
In the institutionalized setting, the interdisciplinary health care team, including family members, must have an awareness of the therapeutic regimen to ensure its proper implementation.
If the patient is directly involved in treatment, he or she must be educated accordingly. When explaining the regimen to a patient, speak slowly, directly and distinctly. Limit comments to essential points, and invite questions after each one. Use examples to illustrate when one would take the medication, and demonstrate if appropriate.
Help the patient become knowledgeable about his or her illness, drug regimen, and therapeutic goals, and encourage the use of memory and compliance aids such as a drug diary or calendar.
Physical limitations
o o o o o
poor visual acuity impaired hearing decreased manual dexterity memory loss dry mouth
factors that include physical limitations, adverse reactions, and health beliefs. These factors are listed on your screen. Awareness of these factors can assist the pharmacist in identifying and reducing potential barriers to successful achievement of therapeutic goals.
Discuss potential side effects Discourage self-medication of symptoms Encourage reporting of new symptoms Report new prescriptions to providers
The pharmacist must consider strategies for avoiding adverse drug reactions and interactions. These strategies include discussing the potential side effects of medications with patients and discouraging the self-medication of symptoms. Encourage the patient to contact you or his or her doctor if new symptoms develop while following the drug regimen. In the institutional environment, physicians, nurses, ancillary service providers, and family and friends need to be aware of the dangers of adverse drug reactions and self-medication, and the importance of reporting changes in cognitive and functional status. Some side effects are expected with certain medications and strategies for management should be discussed. It is important that all health care providers are aware of the entire medication regimen.
Design of a care plan is complete when reasonable goals and expectations are set, interventions are agreed upon, and responsibilities of the practitioner, caregivers, family, and patient are accepted. Once the plan is implemented, the patient must be monitored and evaluated to ensure that therapeutic goals are being met.
03.02.10 Resources For additional information, see: Adamcik, B.A. & Rhodes, R. S. (1993). The pharmacist's role in rational drug therapy of the aged. Drugs Aging; 3(6): 481-486. Anderson, R. J. & Miller, S. W. (1992). Geriatric drug therapy. In: Herfindel ET, Gourley D. R. & Hart L. L., (Eds.). Clinical Pharmacy and Therapeutics, 5th ed. Baltimore: Williams & Wilkins, 1489-1507. Anon. (1992). Guidelines for consultant pharmacists practicing in nursing facilities. Consult Pharm; 7: 1094, 1099. Anon. (1993). Guidelines for consultant pharmacists practicing in residential care facilities. Consult Pharm; 8: 150-153. Delafuente, J. C. (1991). Perspectives on geriatric pharmacotherapy. Pharmacotherapy; 11(3): 222-4. Delafuente, J.C. & Stewart, R.B., (Eds.) (2001). Therapeutics in the elderly, 3rd ed. Cincinnati: Harvey Whitney Books Company. Feinberg, J. L. (1991). Taking responsibility for therapeutic outcomes:barriers to consultant pharmacists. Consult Pharm; 6(12): 958-965. McKenzie, L. C., Kimberlin, C. L., Berardo, D. H., Pendergast, J. F. (1991). Pharmacists care of elderly patients. University of Florida, College of Pharmacy. Wong, B. J., et al. (1994). Role of the pharmacist on a geriatric assessment team. Consult Pharm; 9(10): 1149-1158. Websites: American Society of Health-System Pharmacists http://www.ashp.org American Society of Consultant Pharmacists http://www.ascp.com American Pharmacists Association
03.03.01 Steps in Devising a Therapeutic Monitoring Plan Define Needs Identify Goals Design the Therapeutic Regimen Monitor the Patient:
evaluate plan for safety evaluate patient compliance evaluate plan for effectiveness determine if therapeutic goals are met
Document Patient Progress The design of the pharmaceutical regimen and patient care plan represents the beginning, not the end, of the therapeutic planning process. Once treatment has been initiated, both the patient and the therapeutic regimen must be continually monitored for safety and effectiveness. The impact of therapy on the patients quality of life must also be evaluated on a regular basis. At some point a determination must be made as to whether the therapeutic goals have been met. Data gathered during this monitoring period are used to develop recommendations for modifying the plan.
Side effects Adverse reactions Pharmacodynamic and pharmacokinetic interactions Drug-drug interactions Drug-food interactions
Medications incorporated into every patient care plan must be monitored and reviewed on a regular systematic basis. Federal regulations in long term care facilities require monthly drug regimen reviews. Other institutions may have their own review policies. During these reviews, the safety of the medication is evaluated. Side effects and adverse reactions experienced by the patient are noted, along with any potential pharmacodynamic and pharmacokinetic interactions. Direct observations for adverse drug events and laboratory data should be part of the monitoring process.
Which of the following must always be considered when evaluating medication safety? A. B. C. D. E. Drug-drug interactions Patient's ability to self-administer the drug Risk of environmental contamination Bioavailability All of the above
CORRECT ANSWER: A. While all the listed factors are important, drug-drug interactions must be continuously monitored for and anticipated when evaluating medication safety.
physical limitations cognitive limitations incomplete therapeutic regimens adverse drug reactions financial constraints interfering health beliefs influence of family and friends influence of caregivers
Evaluation Strategies:
review of medication administration record comparison of refill record and directions for use monitoring patient for adverse effects
Another area that must be evaluated during the monitoring process is patient adherence. Nonadherence with the pharmacotherapeutic regimen may be influenced by a variety of factors that include physical and cognitive limitations, financial constraints, and psychosocial factors. Assessment of the medication administration record may reveal adherence issues that need to be addressed. For example, an inconsistency between the refill frequency and directions for use suggest an adherence problem. Continuous monitoring for drug toxicities, tolerance, and adverse effects may uncover additional sources of nonadherence.For more information on medication adherence: http://www.adultmeducation.com/
The monitoring process should evaluate the efficacy of therapy. Is the agent potentially causing, or contributing to, any significant change in the patients status? Is the patient taking any unnecessary medications that should be discontinued? The risk-benefit of each medication must be evaluated on an ongoing basis, and appropriate actions taken in order to optimize the continuing quality of the therapy. 03.03.05 Evaluating Therapeutic Outcomes STATUS Resolved (acute concern) Goals Achieved Yes Progress Continue Discontinue Yes No Yes New Agent Recommended Comment For acute concerns, drug therapy may be
Stable
Yes
Yes
Yes
No
No Not yet
Yes Some
Yes Yes
Not yet No
Little or none No
Depends No
Depends Yes
Depends Yes
discontinued For chronic maintenance therapy, drug therapy may be continued No substantial drug therapy changes made Minor adjustments in care plan may be indicated to meet goals Depends on timing of evaluation Decline in patients health, may require discontinuation after side effect, drug interaction, noncompliance issues assessed Patient dies while receiving drug therapy
Failure Expired
No No
No No
No No
Yes Yes
Yes No
Integral to the monitoring process is the evaluation of therapeutic outcomes. The chart on your screen illustrates the types of patient status indicators that are important in this evaluation. Data collected during this process one is rolled into a recommendation, and reviewed with the multidisciplinary health care team before instituting changes. 03.03.06 Evaluating Therapeutic Outcomes Vital Signs:
respiratory rate
cardiovascular pulmonary fluid and electrolyte status renal functions hepatic functions endocrine functions gastrointestinal GU/ reproductive musculoskeletal neurological psychiatric/psychological skin EENT nutritional status
Appropriate assessment tools and procedures must be used to evaluate the health status of the patient and the degree to which therapeutic goals have been achieved. The patients vital signs should be assessed frequently, depending on the severity of the disorder and pharmacotherapeutic treatment. A check of systems affected by the disorder and its treatment should also be conducted. These assessment data must be analyzed, translated into recommendations, and reviewed with the interdisciplinary health care team before instituting any changes.
The results of the evaluation process should be documented on the patients medication record or individualized monitoring form, either in written or electronic
format. This recorded feedback then becomes the foundation for recommendations as to how to modify the therapeutic plan. For example, from documented evidence of adverse effects experienced by the patient, you may conclude that it is necessary to lower the dosage, alter the administration of the drug, or replace the drug with an alternative that is safer and equally effective. All recommendations should be discussed with the interdisciplinary team.
Logistical Considerations:
The final step in the monitoring process is to determine the appropriate monitoring frequency. The time frame between successive follow-ups should be tied to the therapeutic goal, the nature of the illness, and the characteristics of the medication prescribed. The factors shown here should be considered whenever monitoring frequency is in question. 03.03.09 Resources For additional information, see: Adamcik, B. A. & Rhodes, R. S. (1993). The pharmacist's role in rational drug therapy of the aged. Drugs Aging; 3(6): 481-486.
Anderson, R. J. & Miller, S. W. (1992). Geriatric drug therapy. In: Herfindel, E. T., Gourley, D. R. & Hart L. L., (Eds.). Clinical Pharmacy and Therapeutics, 5th ed. Baltimore: Williams & Wilkins, 1489-1507. Anon. (1992). Guidelines for consultant pharmacists practicing in nursing facilities. Consult Pharm; 7: 1094, 1099. Anon. (1993). Guidelines for consultant pharmacists practicing in residential care facilities. Consult Pharm; 8: 150-153. Bulpitt, C. J. & Fletcher, A. E. (1990). Drug treatment and quality of life in the elderly. Clin Geriatr Med; 6(2): 309-318. Cipolle, R .J., Stroud, L. M., & Marley, P. C. (2004). Pharmaceutical care practice; New York: McGraw Hill. Clark TR, Gruber J, Sey M. The early history and evolution of DRR. Consult Pharm; 2003;3:215-35. Clark TR, Gruber J, Sey M. Revisiting drug regimen review, part II: art or science. Consult Pharm; 2003;6:506-13. Clark TR, Gruber J, Sey M. Revisting drug regimen review, part III: a systematic approach to DRR. Consult Pharm; 2003;8:656-66. Delafuente, J. C. (1991). Perspectives on geriatric pharmacotherapy. Pharmacotherapy; 11(3): 222-4. Delafuente, J.C. & Stewart, R.B., (Eds.) (2001). Therapeutics in the elderly, 3rd ed. Cincinnati: Harvey Whitney Books Company. Faden, R. & German, P. S. (1994). Quality of life. Considerations in geriatrics. Clin Geriatr Med; 10(3): 541-51. Feinberg, J. L. (1991). Taking responsibility for therapeutic outcomes:barriers to consultant pharmacists. Consult Pharm; 6(12): 958-965. McKenzie, L. C., Kimberlin, C. L., Berardo, D. H., Pendergast, J. F. (1991). Pharmacists care of elderly patients. University of Florida, College of Pharmacy. Torg, E. (1992). Life since OBRA: roles and responsibilities of consultant pharmacists and physicians in long-term care. Consult Pharm; 7(12): 12821290. Wong, B. J., et al. (1994). Role of the pharmacist on a geriatric assessment team. Consult Pharm; 9(10): 1149-1158.
Websites: American Society of Health-System Pharmacists http://www.ashp.org American Society of Consultant Pharmacists http://www.ascp.com American Pharmacists Association http://www.aphanet.org/ Agency for Healthcare Research and Quality http://www.ahrq.gov/ Cytochrome P450 Drug Interaction Table http://www.drug-interactions.com
assessment of needs establishment of therapeutic goals design of the therapeutic regimen monitoring and following up schedule achievement of therapeutic outcomes
To promote acceptance of the therapeutic plan To provide a basis for solving health care problems To provide a vehicle for communication among patient, family, and caregivers
Documenting the pharmaceutical care relationship is essential in todays health care environment. All steps of the therapeutic planning process must be documented, from the assessment of patient/family needs and identification of therapeutic goals, to the design of the therapeutic regimen and monitoring plan. Effective documentation using a problem-oriented approach will facilitate plan acceptance, patient-caregiver communication, and achievement of therapeutic outcomes. The time you spend on documenting the pharmaceutical care relationship will aid you and ultimately your patient to resolve his or her health problems. Documentation of the therapeutic plan: A. B. C. D. Is based on a standard problem-solving format Is determined by the healthcare setting Requires the consent of the patient Must be done by hand
CORRECT ANSWER: B. The environment of the healthcare setting where the documentation is occurring will dictate the format in which it is done.
03.04.02 The SOAP Format Identify problem --> Subjective data Quantify data --> Objective data Assess the data --> Assessment Solve the problem --> Plan
The SOAP format provides a problem-oriented method for documenting the pharmaceutical care relationship. SOAP represents a four-step process that consists of identifying the problem with subjective data, quantifying the data objectively with tests if possible, assessing these subjective and objective data and recommending a plan to solve the problem. Each component of the SOAP format is described in the next series of frames. 03.04.03 Documenting Subjective Data
Characteristics of Data:
focuses on patients perspective descriptive in nature can incorporate perspective of family members or other caregivers perspective
listening to patient complaints or symptoms listening to family and primary care givers observations asking questions observing the patient
chief complaint (e.g., pain, fatigue, shortness of breath) mental status (e.g., depressed, anxious,happy) medical status (e.g., worse, no change, better)
When you identify the problem using subjective data, you are really asking how the patient feels and observing what you can regarding his or her health condition. Identifying the problem subjectively can help you quantify it objectively in the next step. Subjective data documentation should be descriptive in nature, and may not be verifiable through tests. This type of data is gathered by listening to the patients complaints or symptoms, and questioning the patient on areas such as the duration of symptoms and effectiveness of therapy. While documenting this information, you will also want to note the patients mental status. Listening to the observations of family members or primary caregivers will provide additional critical information regarding the patients physical and mental status.
Characteristics of Data:
countable measurable
physical examination laboratory tests and procedures imaging procedures assessment instruments
routine patient data (e.g., vital signs, I/O, weight) signs and symptoms (e.g., frequency of behaviors, number of lesions)
tests (e.g., blood count, liver function, urinalysis) studies (e.g., cytological, tissue, stool, or sputum cultures) imaging (e.g., x-ray, CT scan, MRI)
After gathering subjective data and identifying the medical problem, you will want to quantify the problem objectively using laboratory tests and procedures. These tests and procedures may include assessments of hematologic, hepatic, and renal function. Some drugs may require therapeutic serum concentration monitoring for assessment of dosing adequacy and potential for toxicity. With infected patients, blood tests and cytological studies can facilitate antibiotic selection and eradication of the infecting organism. If you have access to the medical record, note the results of physical examinations and laboratory tests already documented in the plan. Include results of additional tests, procedures and assessments in the plan. Keep in mind that objective data should be countable or measurable, and can include vital signs, height and weight, fluid intake and output, and frequency of targeted signs and symptoms, including behaviors.
drug-induced disease induced need for current therapy response to current therapy need for additional therapy aggressiveness of therapy needed alternative approaches
Determine:
Once the subjective and objective data have been collected, you must assess the data in order to determine the need for therapy or the patients response to current therapy. Your assessment should provide clues to the cause of the problem. For example, is the patients condition drug-induced? From your assessment you should also be able to determine the aggressiveness of the therapy needed, and whether it should be implemented in place of or in addition to the patients current therapeutic regimen. 03.04.06 Solve the Problem and Document the Plan
Recommend:
Document:
selected medication(s) medication form and route of administration starting and maintenance dosage dosing schedule and duration of therapy
drugs to avoid therapeutic and toxicity monitoring parameters patient/family/other caregiver education follow up plans
Solving the problem involves documenting the therapeutic plan, including recommendations to continue, discontinue or begin therapy, and the reasons behind the recommendations. If new drug therapy is recommended, document the medication of choice, dose and dosage form, route, schedule and duration. Be sure to note the medications to avoid due to allergies or compliance issues.
Treatment goals, therapeutic and toxicity monitoring parameters, patient education, and future plans, as in follow-ups, should also be noted.
The documentation format is dictated by the practice setting. Some settings for example, have specific policies prohibiting pharmacists to write on the patients chart. If available, the consulting pharmacist should consider using an electronic documentation system for recording therapeutic interventions and outcomes. This format will allow the pharmacist to track patient progress, evaluate the level of success with patient care recommendations, and generate reports for administrative and reimbursement purposes.
patients indication for drug therapy the drug product dosage regimen patients response to therapy
Contents:
the type of medication (e.g., prescription/nonprescription., samples, herbal remedies, vitamins) indication for use (e.g., cure illness, prevent illness, provide comfort, assist in diagnosis, correct abnormal test values)
The medication record outlines the relationship between the patients indication
for drug therapy, the drug product, dosage regimen, and patients response to therapy. It is here that you must list all the drug products that a patient is taking or expected to take. Note in each case the type of medication and whether it is prescription, nonprescription, an herbal remedy, or a vitamin. In each case, you should also document the indication for taking the drug, whether it be for curing an illness, preventing one, or providing comfort from signs and symptoms. 03.04.09 Documenting Outcomes STATUS Resolved (acute concern) Stable Goals Achieved Yes Progress Continue Discontinue Yes No Yes New Agent Recommended Comment For acute concerns, drug therapy may be discontinued. For chronic maintenance therapy, drug therapy may be continued. No substantial drug therapy changes made Minor adjustments in care plan may be indicated to meet goals Depends on timing of evaluation Decline in patients health, may require discontinuation after side effect, drug interaction, noncompliance issues assessed Patient dies while receiving drug therapy
Yes
Yes
Yes
No
No Not yet
Yes Some
Yes Yes
Not yet No
Little or none No
Depends No
Depends Yes
Depends Yes
Failure Expired
No No
No No
No No
Yes Yes
Yes No
When documenting therapeutic outcomes, determine the appropriate status as shown here. Roll feedback into plan, adjusting if necessary and documenting changes. 03.04.10 Resources For additional information, see: Adamcik, B. A. & Rhodes, R. S. (1993). The pharmacist's role in rational drug therapy of the aged. Drugs Aging; 3(6): 481-486. Anderson, R. J. & Miller, S. W. (1992). Geriatric drug therapy. In: Herfindel, E. T., Gourley, D. R. & Hart L. L., (Eds.). Clinical Pharmacy and Therapeutics, 5th ed. Baltimore: Williams & Wilkins, 1489-1507. Anon. (1992). Guidelines for consultant pharmacists practicing in nursing facilities. Consult Pharm; 7: 1094, 1099. Cipolle, R .J., Stroud, L. M., & Marley, P. C. (1998). Pharmaceutical care practice. New York: McGraw Hill. Delafuente, J. C. (1991). Perspectives on geriatric pharmacotherapy. Pharmacotherapy; 11(3): 222-4. Faden, R. & German, P. S. (1994). Quality of life. considerations in geriatrics. Clin Geriatr Med; 10(3): 541-51. Feinberg, J. L. (1991). Taking responsibility for therapeutic outcomes:barriers to consultant pharmacists. Consult Pharm; 6(12): 958-965. McKenzie, L. C., Kimberlin, C. L., Berardo, D. H., Pendergast, J. F. (1991). Pharmacists care of elderly patients. University of Florida, College of Pharmacy. Torg, E. (1992). Life since OBRA: roles and responsibilities of consultant pharmacists and physicians in long-term care. Consult Pharm; 7(12): 1282-1290. Wong, B. J., et al. (1994). Role of the pharmacist on a geriatric assessment team. Consult Pharm; 9(10): 1149-1158. Websites:
American Society of Health-System Pharmacists http://www.ashp.org American Society of Consultant Pharmacists http://www.ascp.com American Pharmacists Association http://www.aphanet.org/ Agency for Healthcare Research and Quality http://www.ahrq.gov/