Pharmaceutical care

Pharmaceutical Care

1. 12/28/2012
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Pharmaceutical Care
MalikAllah BukhshAwan
Lecturer IPS
Objectives
•To differentiate between traditional pharmacy /
Clinical Pharmacy & Pharmaceutical Care
•Process of Pharmaceutical care
•PWDT
•CORE
•PRIME
•FARM
•Documentation of Pharmaceutical care process

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New Trends in Monitoring & Managing
Patient Care
•Pharmacist responsibility to reduce drug related
problems has lead to the concept of pharmaceutical
care
•Reduces the possibility of drug related problems &
enhances the quality of life
•Pharmaceutical care helps in achieving definite
outcome in health care:
–Curing the disease
–Reducing or eliminating symptoms
–Arresting or slowing the disease process
–Preventing the disease or its symptoms
New Trends in Monitoring & Managing
Patient Care cont….
•Monitoring drug therapy and out come is
important for providing pharmaceutical care.
It includes:
–Identifying actual or potential drug related
problems
–Resolvingthe actual drug related problems
–Preventing the potential drug related
problems

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Pharmaceutical Care
•Pharmaceutical care describes specific
activities and services through which the
individual pharmacist “ co-operate with the
patient and other professionalsin designing,
Implementing, and monitoringa therapeutic
planthat will produce specific therapeutic
outcomes for the patient.”
Pharmaceutical Care
ROLE:
Pharmaceutical care has evolved from an emphasis
on prevention of drug-related problem
Function:
•It does not imply that the pharmacist is no longer
responsible for dispensing function.
•Rather redesign of professional work flow, with
assignment of technical functions to technical
personnel under the direct supervision and
responsibility of the Pharmacist.

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Traditional
Pharmacy
Clinical
Pharmacy
Pharmaceutical
Care
Primary
Focus
Prescription
order and
OTC
order
Physician or
other health
professionals
Patient
ContinuityUpon demandDiscontinuousContinuous
Strategy Obey Find fault or
prevention
Anticipate or
improve
Orientation Drug product Process Outcomes
Uniqueness Of Pharmaceutical Care
Essential Components of Pharmaceutical
Care
Pharmacist work up of drug therapy
(PWDT)

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EPharmacist work up of drug therapy
(PWDT)WDT
1.Data Collection
2.Develop or identify the CORE pharmacotherapy
3.Identify the PRIMEpharmacotherapy problems
4.Formulate a FARMprogress note
Data Collection
Collects, synthesize, interpret relevant
information, such as:
(a) Patient demographic data: age, race, sex
(b) Patient medical information
(i) Current and past medical history
(ii) Family history
(iii) Social history
(iv) Dietary history

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1-Data Collection Cont……
(v)Medication history (prescription, OTC, social
drugs, allergies)
(vi)Physical findings( weight, height, blood
pressure, edema)
(vii) Laboratory or other test result (eg: serum
drug level, potassium level, serum creatinineas
relevant to drug therapy)
(viii) Patient complaints, symptoms, signs
Data Collection
Develop or identify the CORE pharmacotherapy
Develop or identify
C=Condition or patient need
O=outcomes desired for that condition
(Patient &Therapeutic end point)
R= Regimen selected to achieve that outcome
1. Therapy regimens: Existing therapy & initial therapy)
2. Goal setting & behavior regimens:
E= Evaluation parameters to assess outcome achievement
1. Efficacy parameters
2. Toxicity Parameters

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3Identify the PRIMEPharmacotherapy
problems
The goal of PRIME is to identify actual or
potential problems that could compromise the
desired patient outcomes.
P=Pharmaceuticalbased problems
R=Riskto patient
I=Interaction
M=Mismatch b/w medications and condition or
patient needs
E=Efficacy issues
3-PRIME pharmacotherapy problems
Cont….
P = Pharmaceutical…….asses for incorrect
* dose *form *monitoring
* route *timing
*duration *frequency
R= Risks to patient……..assess for
* known contraindications
* patient medication allergy
* drug-induced problems
* improper utilization
* common/serious adverse effects
* medication error considerations

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3-PRIME pharmacotherapy problems
Cont….
I=Interaction …….assess for
*drug-drug *drug-disease
*drug-food *drug-lab
M=Mismatch ….assess for
*Medications used without indication
* indication, condition, or complaint untreated
* Actual barriers to implementation of medication or
behavior regimens
3-PRIME pharmacotherapy problems
Cont….
E = Efficacy issues ……assess for
*suboptimal selection of pharmacotherapy for
indication
* too much correct drug
* minimal or no evidence of therapeutic effectiveness
* suboptimal utilization of pharmacotherapy
* patient preference considerations (e.g. undesirable
prior experiences with medication, does not believe it
works)
* medication availability considerations
* compliance or administration considerations ( e.g
inability to pay, unable to administer correctly or at all)

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Formulate a FARMprogress note
FARM progress notes to describe and document
the interventions intended or provided by the
pharmacist.
4-FARM progress note cont…
F=Findings:
the patient specific information that gives a basis for, or leads to, the
recognition of a pharmacotherapy problem or indication for pharmacist
intervention.
A=Assessment:
the pharmacist’s evaluation of findings, including a statement
(i) any additional information needed to assess the problem
(ii) severity, priority or urgency of the problem
(iii) short term and long term goals of the intervention
Formulate a FARMprogress note

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4-FARM progress note cont…
R=Resolution (including prevention):
the intervention plan includes actual or proposed actions by the
pharmacist. The intervention options may include:
*counseling or educating the patient
* making recommendations to the patient and caregiver
* informing the prescribers
* making recommendations to the prescribers
* withholding medication or advising against use
Formulate a FARMprogress note
4-FARM progress note cont…
M=Monitoring and follow up:
the parameters and timing of follow up monitoring to assess
the efficacy, safety and out come of the intervention. It
includes:
(i) parameters to be followed
(ii) intent of the monitoring
(iii) ways of monitoring the parameters
(iv) frequency of monitoring
(v) duration of monitoring
(vi) anticipated or desired finding
(vii) decision point to alter the therapy
Formulate a FARMprogress note

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Managerial skills
•Plan
•Direct
•& Implement
pharmaceutical care activities within
various practicing environments, such as
community pharmacy, ambulatory care
settings, home health services, inpatient
hospital practice and others.
Formulate a FARMprogress note
WORKUP OF DRUG WORKUP OF DRUG
THERAPY IN THERAPY IN
PHARMACEUTICAL CAREPHARMACEUTICAL CARE
Patient name: ____________________
Date: ____________________
Case: ____________________
Pharmacist: ____________________
Problem Oriented Pharmacist Record

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PATIENT DATABASE1
A. Patient Description
Name: ________________ Age: ____________years
Reg. no: ________________ Sex: ________________
Weight: ________________ Admission: ______________
Race: _____________ Height: ______________
B. Chief Complaint (CC) ___________________________________________
_______________________________________________________________________
_______________________________________________________________________
C. History Of Present Illness (HPI) __________________________________
_________________________________________________________________________________
_____________________________________________________________
D. Past Medical History (PMHx)
PrescriptionResolveOnsetDisease
E. Compliance Good  Moderate  Poor 
Comments: __________________________________________________________________
F. Histories Of AllergiesYes  No  Not known 
Type: _________________________________________________________________________
G. Social History (Soc. Hx)
Smoking: Yes  No  Not known 
Alcohol: Yes  No  Not known 
H. Medication History
1. Is the patient currently or within the past three months taking medication(s) which require a prescription?
Yes No ,if yes please identify, list and describe (including drug, dose, regimen, duration and use)
_______________________________________________________________________________________
_______________________________________________________________________________________
2. Is the patient currently taking OTC medication(s)? Yes No ,if yes please identify, list and describe
(including drug, dose, regimen, duration and use)
_______________________________________________________________________________________
_______________________________________________________________________________________
3. Medication history assessment:
Patient non compliance _______________________________________________________________
Inadequate medication knowledge _______________________________________________________
Inappropriate medication use ___________________________________________________________
Inadequate communication with health professional _________________________________________
ADR ______________________________________________________________________________
Other medication related problems ______________________________________________________
I. Pharmacologic Review Of System
Comment:
EENT:
Fluid status:
Neuro/Mental:
Skin/Muscle:
ABDO:
BLOOD:
CHEST:
CVS:
Hepatic:
KUT:
VS:
General status:

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J. Laboratory
X-Ray2HPP/INS
ECGBUN/Ser
ONC/MAPPLTS
CO/ClEOS/BSO
PAS/PADLYM/MNO
PWP/CVPPMN/BND
CI/AOOHHgb/HCT
AA/GLUWBC/RBC
WTPEEP/CPAP
I/O RR/Vent
HR/Temp(maxPO
2 / %
BP: S/DpCO
2 / HCO
3
-1
TT / FDPpH / Osat
PT /aPPTAl/ TP
BLI/APstMg/UA
CPK/MBESR
AMY/LDHCa
+2
/PO
4
-2
SGOT/GGTCl
-1
/HCO­­­
3
-1
FBS/RBSNa
+
/K
DateDate
Sensitivit
y
IsolateSourceDateDose changeSCon.DrugDate
Others:___________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
K. Diagnosis / Provisional Dx / Medical Problem List ___________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

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L. Drug Treatment In Ward
Comments
Othe
rs
`Cos
t
Dura
tion
Drug
Dupl
icati
on
Drug
-
Dise
ase
Inter
actio
n
Dru
g-
Dru
g
Inter
actio
n
Dire
ctio
n
Dosag
e
Effec
tiven
ess
Indic
ation
StopStartDrug regimen
Assessment Factors: 1 => Indicated, Effective, Correct, Practical, Insignificant,
Necessary, Acceptable, Least expensive
2 => Not Indicated, Ineffective, Incorrect, Impractical, Significant,
Unnecessary, Unacceptable, Most expensive
3 => Don’t know (unable to assess)
2 PATIENT SPECIFIC, DRUG RELATED PROBLEM LIST
Category 1: Medical Indication For A Drug
Category 2: too little of the correct drug
Category 3: too much of correct drug
A new medical problem requiring a drug therapy: ______________________________________
______________________________________________________________________________
Continuity of a drug therapy: _______________________________________________________
_______________________________________________________________________________
Prophylaxis or premedication: ______________________________________________________
_______________________________________________________________________________
Synergism or potentiation (desired combination Rx): ____________________________________
_______________________________________________________________________________
Others: ________________________________________________________________________
Dose too low (wrong dose error): ___________________________________________________
Sub therapeutic drug concentration: __________________________________________________
Timing prophylaxis (too early, presurgical, antibiotics): __________________________________
Drug, route, dosage form, formulation, conversion, deteriorated drug: _______________________
Monitoring error: ________________________________________________________________
Others:_________________________________________________________________________
Dose too high (wrong dose error/extra dose error): _____________________________________
Toxic drug concentration: _________________________________________________________
Too-rapid dose escalation/ wrong rate or administration: _________________________________
Dose-accumulation: _____________________________________________________________
Drug, route, dosage form, formulation, conversion problem: ______________________________
Dose and interval flexibility miscued (wrong time): _____________________________________
Monitoring error: ________________________________________________________________
Others: ________________________________________________________________________

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Category 4: wrong drug
Category 5: problem secondary to an ADR
Category 6: drug-drug, drug-food, drug-laboratory test interaction
Drug not effective for indication: ____________________________________________________
Allergies to medication: ___________________________________________________________
Not the most effective: ____________________________________________________________
Contraindication: ________________________________________________________________
Effective, yet not the most economical choice: _________________________________________
Effective, yet not the safest pharmacotherapy: _________________________________________
Resistant organism: ______________________________________________________________
Refractory to present drug: _________________________________________________________
Unnecessary drug combination when single drug is appropriate: ___________________________
Monitoring error: ________________________________________________________________
Others: ________________________________________________________________________
Drug administration problem (too rapid): ________________________________
Prescribing issue (allergic reaction): ____________________________________
Patient risk factors: _________________________________________________
Idiosyncratic reaction: _______________________________________________
Monitoring error: ___________________________________________________
Others: ___________________________________________________________
Drug food: _____________________________________________________________________
Physical interaction (reduce bioavailability): ___________________________________________
Increase or inhibit excretion: _______________________________________________________
Enzyme induction/inhibition: _______________________________________________________
Decreased absorption of one of the drugs: _____________________________________________
Displacement from binding sites: ____________________________________________________
Laboratory test interference: _______________________________________________________
Synergism or potentiation: _________________________________________________________
Others: ________________________________________________________________________
Category 7: problem due to patient not receiving drug
Category 8: no valid medical indication
Category 9: miscellaneous
Medications errors (omission error), medication knowledge: ______________________________
Patient Non-compliance: ___________________________________________________________
Socio-Economics: ________________________________________________________________
Patient Health beliefs/Satisfaction: __________________________________________________
Others: ________________________________________________________________________
Drug abuse: ____________________________________________________________________
Unapproved indication: ___________________________________________________________
Polypharmacy: __________________________________________________________________
Inappropriate use of OTC: _________________________________________________________
Unauthorized drug error: __________________________________________________________
Others: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

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3DESIRED PHARMACOTHERAPEUTIC OUTCOMES FOR EACH
DRUG-RELATED PROBLEM
i. _________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
ii ._________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
iii._________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
iv._________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
v. _________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
vi._________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
vii.________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
viii.________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
ix._________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
4FEASIBLE PHARMACOTHERAPEUTIC ALTERNATIVES FOR EACH DRUG -RELATED
PROBLEM
Comments Supply
Interact
ion
Predicta
bility
CostSafety
Dosage
Practica
lity
Efficacy
Alternatives (drug,
dose, dosage form,
frequency, route and
duration)
1 => Effective, Practical, Safe, Least expensive, Predictable, Insignificant,
Standard drug
2 => unapproved, least practical, more toxic, expensive, unpredictable,
Significant, special request
3 => Don’t know (not enough data to evaluate)

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5CHOOSE THE ‘BEST’ PHARMACOTHERAPEUTIC SOLUTION AND
INDIVIDUALIZE THE THERAPEUTIC REGIMEN
6THERAPEUTIC DRUG -MONITORING PLAN
i.__________________________________________________________________________________
ii.__________________________________________________________________________________
iii.__________________________________________________________________________________
iv._________________________________________________________________________________
v.__________________________________________________________________________________
vi._________________________________________________________________________________
vii._________________________________________________________________________________
viii.________________________________________________________________________________
ix.__________________________________________________________________________________
i.__________________________________________________________________________________
ii.__________________________________________________________________________________
iii.__________________________________________________________________________________
iv._________________________________________________________________________________
v._________________________________________________________________________________
vi.__________________________________________________________________________________
vii._________________________________________________________________________________
viii._________________________________________________________________________________
ix.__________________________________________________________________________________
7IMPLEMENT THE INDIVIDUALIZED REGIMEN AND
MONITORING PLAN
(viii)
(vii)
(vi)
(v)
(iv)
(iii)
(ii)
(i)
Comments
Acceptance
Code
Pharmaceutical Care
Recommendation
(Communication)
Acceptance code: Y = Yes, recommendation accepted,
N = recommendation rejected.
C = Yes, recommendation accepted but with changes

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8 FOLLOW UP
Subjective, Objective, Assessment and new DPR, Plan (SOAP)Date
9 DISCHARGE SUMMARY AND COMMUNICATION
A. SUMMARY________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
B. COMMUNICATION
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
____________________________________________________________________

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Data Collection
1-Review patient medical record
2-Review medication profile
3-Interview patient
Develop or identified the CORE Pharmacotherapy plan
Identify the drug related problems or patient needs PRIME
Formulate a pharmaceutical care plan
Communicate plan with patient health care team
Document actions taken in patient medical record
Follow Up
Thank you