Pharmacist's Management of Drug Related Problems

(PMDRP)

Developmental Group Members:

Nancy Winslade, Pharm.D.
Jana Bajcar, M.Sc.Phm.
Anne-Marie Bombassaro, Pharm.D.
Ciro Caravaggio, Pharm.D.
Dawn Strong, Pharm.D.
Sharon Yamashita, Pharm.D.

In addition to the above individuals, contribution to subsequent revisions was made by:
Lori Blain, B.Sc.Phm.
Susan Bowles, Pharm.D.
Michelle Foisy, Pharm.D.
Glen Pearson, Pharm.D.
Choo Pin Por, Pharm.D.
John Pugsley, Pharm.D.
Pharm.D. students in the Doctor of Pharmacy Program,
Faculty of Pharmacy, University of Toronto

For more information please contact:

Pharm.D. Office
Pharm.D. Program
Faculty of Pharmacy
University of Toronto
19 Russell St.
Toronto, Ontario
Revised, January 1994
The authors acknowledge that the PMDRP incorporates concepts from both the Pharmacist's Workup of Drug Therapy
(PWDT) by Strand L., Cipolle R., Morley P. and the Pharmacist's Workup of Drug Related Problems by Ramsey R.

PMDRP - 1993
PHARMACIST'S MANAGEMENT OF DRUG RELATED PROBLEMS
Date:

Pharmacist:

A.
Name:

DOA:

Gender:M / F Race:

Ht:

Age:
ABW:

IBW:

Current Chief Complaint/Reason for Pharmacist Review.

Are patients with these characteristics predisposed to specific diseases which may require drug treatment? If they are more likely to have
specific diseases, what signs/symptoms or laboratory values would you look for to indicate the presence of these diseases? (briefly)
Medical Condition
Signs/symptoms
Medical Conditions
Signs/ Symptoms

Do they have alterations in drug efficacy (pharmacokinetic, pharmacodynamic) which may require alterations in drug choices? Are they
predisposed to drug toxicity which may require altered doses or drug choices?
Factors that may affect response or efficacy:
Factors that may increase toxicity:

Are they predisposed to factors which may affect their compliance or drug taking behaviour (eg. memory deficits, certain cultural
backgrounds)?

Based on your assessment up to this point, what drug related issues will you need to keep in mind for this patient:
1. [No indication]
Explanation:
2. [Indication]
Explanation:
3. [Wrong Drug]
Explanation:
4. [Low Dose]
Explanation:
5. [High Dose]
Explanation:
6. [Not administered properly] Explanation:
7. [ADR] Explanation:
8. [Drug Interaction]Explanation:

B.

ALLERGIES AND INTOLERANCE:

Drug

Description, Date, Time frame, of Reaction

Contraindication to present or future therapy?

C. PRESENT DRUG THERAPY AND MEDICAL PROBLEMS/DISORDERS.

Medical Problem

Note:

Date of
Onset

Drug Therapy

Start
date

Stop
date

Response *
(R,W,I,NC)

Response*: R-Resolved W-Worse I-Improved NC-No change

C. PRESENT DRUG THERAPY AND MEDICAL PROBLEMS/DISORDERS (continued).

Medical Problem

Date of
Onset

Drug Therapy

Start
date

Stop
date

Response *
(R,W,I,NC)

Note:

Response*: R-Resolved W-Worse I-Improved NC-No change

Present Medical Problems:

Could any of the
patient's current
medical
problems:
be caused by drug
therapy that the patient
is currently taking, or
has recently taken, or
be
precipitated/aggravate
d by any drug the
patient has a high
probability to take in
the future?

suggest an indication
for drug therapy
(treatment or
prophylaxis of original
condition or common
related complications)?

If there is an indication
for drug therapy and a
drug is currently being
given, is it the best1
drug for the patient? If
the best drug, why is it
not working 2?

CURRENT MEDICAL PROBLEMS

affect the present or

future therapeutic plan
(drug choices, dose,
frequency, route,
formulation, duration)?

1. Compare effective alternatives based on efficacy, time frame, toxicity, drug interactions, convenience, and cost.
2. Reasons why the best drug may not be working may include: low dose, drug interaction, drug not being taken as prescribed, need additional therapy,
unexplained.

Present Medical Problems:

Could any of the
patient's current
medical
problems:
be caused by drug
therapy that the patient
is currently taking, or
has recently taken, or
be
precipitated/aggravate
d by any drug the
patient has a high
probability to take in
the future?

suggest an indication
for drug therapy
(treatment or
prophylaxis of original
condition or common
related complications)?

If there is an indication
for drug therapy and a
drug is currently being
given, is it the best1
drug for the patient? If
the best drug, why is it
not working 2?

CURRENT MEDICAL PROBLEMS

affect the present or

future therapeutic plan
(drug choices, dose,
frequency, route,
formulation, duration)?

1. Compare effective alternatives based on efficacy, time frame, toxicity, drug interactions, convenience, and cost.
2. Reasons why the best drug may not be working may include: low dose, drug interaction, drug not being taken as prescribed, need additional therapy,
unexplained.

Present Medications:
What organ systems can these medications be affecting (efficacy/toxicity)? What signs, symptoms or laboratory
values are needed to determine therapeutic effectiveness and/or toxicity? Circle the parameters that are the
most realistic to follow in this patient?
ORGAN
SYSTEM
Vital Signs
Renal

Liver
CV

Fluid/ Electrolytes

Pulmonary

Endocrine
Hematology

GI
Reproductive
MSK
CNS
Dermatology
ENT
Drug Levels
C/S
Has the medication
produced the desired
therapeutic outcomes
without toxicity?

Can this medication 8

toxicity or 9 efficacy of

DRUGS (E: efficacy T: toxicity)

other medications?
If patient has not
developed drug toxicity
but has a high potential,
is there an indication for
prophylactic therapy? If
yes and the patient is
currently on a drug, is it
the best one for this
patient?

Present Medications:
What organ systems can these medications be affecting (efficacy/toxicity)? What signs, symptoms or laboratory
values are needed to determine therapeutic effectiveness and/or toxicity? Circle the parameters that are the
most realistic to follow in this patient?
ORGAN
SYSTEM
Vital Signs
Renal

Liver
CV

Fluid/ Electrolytes

Pulmonary

Endocrine
Hematology

GI
Reproductive
MSK
CNS
Dermatology
ENT
Drug Levels
C/S
Has the medication
produced the desired
therapeutic outcomes
without toxicity?

Can this medication 8

toxicity or 9 efficacy of
other medications?
If patient has not

DRUGS (E: efficacy T: toxicity)

developed drug toxicity

but has a high potential,
is there an indication for
prophylactic therapy? If
yes and the patient is
currently on a drug, is it
the best one for this
patient?

D.

PAST DRUG THERAPY AND IMMUNIZATION HISTORY

Medical Problem(s)

Onset/
Resolved

Drugs Received/Doses

Start date

Stop date

Response *
(R,W,I,NC)

Note: Response*: R-Resolved W-Worse I-Improved NC-No change

D.

PAST DRUG THERAPY AND IMMUNIZATION HISTORY (continued)

Medical Problem(s)

Onset/

Drugs Received/Doses

Start

Stop

Response *

Resolved

date

date

(R,W,I,NC)

Note: Response*: R-Resolved W-Worse I-Improved NC-No change

Past Medical Problems and Medications:

Could any of:
i.

the current medical problems be caused by a past medication (eg. delayed skin rash)?

ii.

the past medical problems have been caused by a past medication, thus affecting a current therapeutic plan? (eg.
history of GI bleed secondary to NSAIDs in a patient with new onset Rheumatoid Arthritis)

iii.

the past medical problems indicate a need for present drug therapy? (eg. history of rheumatic heart disease or
recurrent DVT)?

iv.

the past responses to therapy affect a current or future therapeutic plan? (eg. previous success with haloperidol
for schizophrenia)?

E.

SOCIAL HISTORY:
Tobacco Use: Y / N (
ppd
Alcohol Use: Y / N (amount:

years) Recreational Drug Use: Y / N Type:

) Special Diet: Y / N

i.

Could any of the patient's medical problems be caused by these factors?

ii.

Do any of these factors require drug therapy?

iii.

Could any of these factors affect a current or future therapeutic plan?

F.

FAMILY HISTORY:

Medical/Drug
Therapy History
Existence of
disease

Family Data

Drug Therapy
i. Efficacy
ii. Toxicity

Family History:
Are patients with this family history more likely to have specific drug related problems?
i.

are they predisposed to specific diseases which may require drug treatment? (Cardiac disease)

if they are more likely to have specific diseases, what signs/symptoms or laboratory values would you look for to
indicate the presence of these diseases? (briefly)

ii.

do they have alterations in drug efficacy (pharmacokinetic, pharmacodynamic) which may require alterations in
drug choices? Are they predisposed to drug toxicity which may require altered doses or drug choices?

G.

COMPLIANCE HISTORY:

Not able to complete

Is the patient responsible for his/her own drug taking? If not, who is?

How reliable is your source of information?

What is the patient's or care-giver's understanding of the instructions for taking the medications?

Do past therapeutic failures or toxicity suggest noncompliance?

What social, economic and/or living conditions might affect this patient's compliance?

H. REVIEW OF SYSTEMS:
Are there any
deviations from
normal which:
VITAL SIGNS:
1) could be
caused by drug
therapy?
2) require drug
treatment?
3) affect your

Date

Temp

COMMENTS

therapeutic
plan?
BP

RENAL/GU:
1) could be
caused by drug
therapy?
2) require drug
treatment?
3) affect your
therapeutic
plan?

HR
RR
Cr

CrCL
urea
output
dysuria
incontinenc
e
dialysis

urinalysis

LIVER:
1) could be
caused by drug
therapy?
2) require drug
treatment?
3) affect your
therapeutic
plan?

AST

ALT
bilirubin

albumin

REVIEW OF SYSTEMS: con't

Are there any
deviations from
normal which:
CARDIOVASCULAR
1) could be
caused by drug
therapy?
2) require drug
treatment?
3) affect your
therapeutic plan?

Date

rhythm

EKG
angina
CPK
LDL/HDL
CO/CI
SVR
PCWP

FLUID &
ELECTROLYTES
1) could be
caused by
therapy?
2) require drug
treatment?
3) affect your
therapeutic plan?

Na

K
Cl
HCO3
Ca
Mg
phosphoro
us
In/Out
edema
CVP
wt. change

COMMENTS

PULMONARY
1) could be
caused by drug
therapy?
2) require drug
treatment?
3) affect your
therapeutic plan?

CXR

ABG pH
CO2
O2

FI O2
dyspnea
wheezing
rales
PFT

REVIEW OF SYSTEMS: con't

Are there deviations
from normal which:
ENDOCRINE
1) could be caused
by drug therapy?
2) require drug
treatment?
3) affect your
therapeutic plan?

Date
BS

T4
TSH
rT3
HAEMATOLOGY
1) could be caused
by drug therapy?
2) require drug
treatment?
3) affect your
therapeutic plan?

Hgb

MCV
WBC
diff.

platelets
PT

COMMENTS

PTT
GI:
1) could be caused
by drug therapy?
2) require drug
treatment?
3) affect drug
absorption?
4) affect your
therapeutic plan?

diarrhea

consti-pa
tion
N/V
bleeding
NPO
feeding
tube
pain

REPRODUCTIVE:
1) could be caused
by drug therapy?
2) require drug
treatment?
3) affect your
therapeutic plan?

pregnant

pain
lactation
impotenc
e
MSK:
1) could be caused
by drug therapy?
2) require drug
treatment?
3) affect your
therapeutic plan?

pain

headach
e
migraine
mobility

REVIEW OF SYSTEMS: con't

Are there any
deviations

DATE

COMMENTS

from normal
which:
CNS:
1) could be
caused by
drug therapy?
2) require
drug
treatment?
3) affect your
therapeutic
plan?

LOC

oriented
memory
agitated
depresse
d
psychotic
nystagmu
s
seizures
DERMATOLOGY:
1) could be
caused by
drug therapy?
2) require
drug
treatment?
3) affect your
therapeutic
plan?

ENT:
1) could be
caused by
drug therapy?
2) require
drug
treatment?
3) affect your
therapeutic
plan?

rash

dermatitis
dry
itchy
decubiti
IV site
allergies

hearing
congestio
n
swallowin

g
vision
DRUG
LEVELS:
1) are causing
toxicity?
2) are
compromising
efficacy?

MICROBIOLOGY
1) could be
caused by
drug therapy?
2) require
drug
treatment?
3) affect your
therapeutic
plan?

Date/Site

Organism

Resistant
antibiotics

Sensitive antibiotics

COMMENTS:

TO DO LIST:
What further information must you gather from the patient, the physician, or from the literature sources before you can
identify the patient's drug related problems.
Patient/Family

Physician/Nurse

Literature

IDENTIFICATION OF DRUG RELATED PROBLEMS (Utilizing the Therapeutic Thought

Process):
Patient is experiencing or has the potential to experience an undesirable sign or symptom because:
1.
2.
3.
4.
5.
6.
7.
8.

the patient is taking/receiving a drug for which there is no valid indication

the patient requires drug therapy for an indication and is not receiving/taking this therapy
the patient is taking/receiving the wrong drug or drug product
the patient is taking/receiving too little drug
the patient is taking/receiving too much drug
the patient is not taking/receiving the prescribed drug appropriately
the patient is experiencing an adverse drug reaction (defined as not dose-related)
the patient is experiencing a drug-drug, drug-food, or drug laboratory interaction

LIST AND PRIORIZE ACTUAL OR POTENTIAL DRUG RELATED PROBLEMS

DRP
#

DRUG RELATED PROBLEM

(Actual or potential sign or symptom
followed by relationship to drug therapy)

Desired
Clinical
Outcome *

Date ID

Priority
& responsibility

Date
Resolved

NOTE: DESIRED CLINICAL OUTCOMES 6 1) to cure a disease 2) to reduce or eliminate a patient's symptomatology 3)
to arrest or slow a disease process 4) to prevent a disease or symptoms and 5) normalize a physiologic parameter.

PHARMACY CARE PLAN:PAGE:

PATIENT NAME:

NURSING UNIT:

DRUG
RELATED
PROBLEM

OUTCOMES

ASSESSMENT

THERAPEUTIC
PLAN

THERAPEUTIC
PLAN
ENDPOINTS

MONITORING
PLAN

For which
problems will
the
pharmacist
assume
responsibility
and solve for
this patient?

For the specific

DRP, what
is/are the:
a) clinical
outcome
b)
pharmacotherap
eutic outcome
c)
pharmacotherap
eutic
endpoints1?

List and assess all

the reasonable drug
and non-drug
therapy which could
produce the desired
pharmacotherapeuti
c endpoints? What
are the risks and
benefits of each
potential alternative
drug or non-drug
regimen?

For this patient which

drug or non-drug
regimen should be
instituted or changes
made in the existing
drug therapy? (drug,
dose, frequency, route
schedule, duration,
formulation)?

What are the

desired and
undesired
endpoints1

For each desired

and undesired
endpoint,
determine:
a) who will monitor
b) when to begin
c) when to stop
d) how follow-up
will occur.

associated with the

specific Therapeutic
Plan?

PE
MET?

1. Endpoint is defined by a specific parameter, the degree of change in this parameter which is un/desired and the time frames in which the
change should occur.
This Pharmacy Care Plan is a component of the PMDRP (Pharmacist's Management of Drug Related Problems) patient assessment form.
Copyright 1993, Faculty of Pharmacy, University of Toronto.

PHARMACY CARE PLAN:PAGE:

PATIENT NAME:
DRUG
RELATED
PROBLEM

OUTCOMES:
A) Clinical
B) Pharmacotherapeutic
C) Pharmacotherapeutic
endpoints1

NURSING UNIT:
ALTERNATIVES

THERAPEUTIC
PLAN

THERAPEUTIC
PLAN ENDPOINTS

MONITORING
PLAN

PE MET?

1. Endpoint is defined by a specific parameter, the degree of change in this parameter which is un/desired and the time frames in which the
change should occur.