1. Documentation of pharmaceutical care

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

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

4. 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

5. 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.

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

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

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

9. 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.

10. 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.

11. 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 )

12. 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”

13. 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)

14. 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.

15. 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.

16. 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

17. SOAP note
HCP: health care provider

18. SOAP and FARM

19. 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

20. 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

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

22. 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

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

24. 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

25. 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

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

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