care planning in pharmacy

Continuing Professional Pharmacy Development Program

Care Planning in Pharmacy

Nadir Kheir1, PhD, B.Pharm

Ahmed Awaisu1, Ph.D, B.Pharm

Talal Naser2, PharmD, B.Pharm

1College of Pharmacy, Qatar University, Doha, Qatar 2Hamad General Hospital, HMC, Doha, Qatar

Learning Objectives

By the end of this workshop, you will able to:

1. Discuss the context, the similarities, and the differences

between the SOAP notes and the Care Plan

2. Define the parts of a SOAP note and a Care Plan

3. Explain the aim of the care plan developed in the process

of “Pharmaceutical Care”

4. List and explain all the activities necessary to develop a

care plan and the responsibilities associated with these

activities

5. Describe the processes to be adopted in order to develop

desired goals of therapy

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Overall Objective

• To provide the participants with the knowledge and

skills necessary to develop patient-centered and

clinically sound care plans for use in the hospital or

community pharmacy setting


The “What” of Care Planning? Defining Care Planning

Ahmed Awaisu, PhD


Defining Care Planning

• Care planning involves systematically assessing a

patient's health problems and needs, setting objectives,

performing interventions, and evaluating results

• Prioritize – Not all patients require a written PPCP

• Assess your own patients and identify specific areas on

which to focus

• Patients with specific diseases (asthma, HTN, DM,

dyslipidemia)


NAPRA. Developing a Pharmaceutical Care Plan. 2007.

Defining Care Planning…

Step 1. Gathering

Information

Step 2. Identifying Problems

Step 3. Assessing Problems

Step 4. Developing

the Plan

Step 5. Evaluating

Achievement of Outcomes


NAPRA. Developing a Pharmaceutical Care Plan. 2007.

• The development of a PPCP can be summarized as a five

step process involving the SOAP format



Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: The clinician’s guide. 2nd Edition.

New York: McGraw Hill; 2004.

The “Why” of Care Planning? Reasons for Documentation


Reasons for Documenting Care

• A systematic way of practice

• Provides permanent record of patient encounter

• Efficient communication with others

• Provides evidence of pharmacist’s actions

• Serves as legal record of care provided

• Help back-up for billing

• Format: PWDT, MDTM,FARM,SOAP etc.

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The “Structure” of a Care Plan? History of Documenting a Pharmaceutical

Care Plan


Documenting a Care Plan

SOAP Note

Subjective Objective Assessment Plan

FARM Note

Finding Assessment Recommend Monitoring

DAP Note

Data Assessment Plan

DRP Note

DRP Recommend Plan


Documenting a Care Plan…


HOAP Format

History Observation Assessment Plan

Expanded – SOAP Format

Subjective Objective Assessment Plan Goals Monitoring Education

SOAP Format

Subjective Objective Assessment Plan

Hurley SC. A Method of Documenting Pharmaceutical Care Utilizing Pharmaceutical Diagnosis. AJPE.

1998;68:119-127.

Documenting a Care Plan…


FARM Format

Findings Assessment Resolution Monitoring

DAR Format

Data Action Response

SOAPIER Format

Subjective Objective Assessment Plan Implement Evaluation Revision


1998;68:119-127.

Documenting a Care Plan The SOAP Note

• SOAP: Subjective, Objective, Assessment, Plan

• A method of documentation employed by health care

providers to write out notes in a patient's chart, along with

other common formats, such as the admission note

• All medical, surgical, nursing specialties use the SOAP notes

• Useful tool to pass along information when transitioning

patient care from one person to another:

– Shift changes

– From one healthcare field to another

– Guidance for future encounters

• Also, useful tool for use by the practitioner in the routine care

for the patient


Subjective

Information the pt tells you about him/herself:

1. Chief Complaint (CC) …46yo M presents to pharmacy for hypertension

2. History of Present Illness (HPI) …pt reports elevated readings for 2

weeks

3. Past Medical History (PMH) …has had DM II for 6 years, HTN for 10

years

4. Drug History (DH) …currently taking metformin 1000mg BID, HCTZ

25mg daily

5. Family History (FH) …DMII in both siblings, father died of MI at 52yo

6. Social History (SH) …denies alcohol, illicit drugs. Smokes 1 ppd.

Adheres to diet ~50% of the time


Documenting a Care Plan The SOAP Note…

Objective

Observable/factual information obtained from or

verified by a healthcare provider

• Vital signs (BP, HR, RR, temp, wt, ht)

• Physical Exam

• Labs (blood tests, urine tests, microbiology, etc)

• Diagnostic tests (x-rays, CT/MRI, EKG, EEG)

• Medications (from profile or chart)



Assessment

Your clinical judgment of the patient’s DRPs

• Problem list (numbered)

• Each item should include

– problem, solution, evidence/reason for your solution

• Prioritize problems

– start with most urgent (usually relates to CC)

– end with least urgent

…HTN is currently uncontrolled on HCTZ alone. Pt should be on

combo therapy with an ACE-Inhibitor per JNC-7 guidelines.



Plan

• Specific solution for each problem outlined in the

assessment

• Numbered list to match the Assessment

• Recommendations for drug dose, frequency,

duration

• Monitoring

• Follow-up



Documenting a Care Plan Systematic Approaches to Care Planning


PWDT

• Pharmacist’s

• Workup of

• Drug

• Therapy

PMDRP

• Pharmacist’s

• Monitoring of

• Drug

• Related

• Problems

PPCP

• Pharmacist’s

• Care

• Plan


1998;68:119-127.

Documenting a Care Plan Systematic Approaches to Care Planning…


Pharmacist’s Workup of Drug Therapy (PWDT)

• Establishing patient-specific data-base

• Identifying patient-specific drug-related problems

• Describing desired therapeutic outcomes

• Listing all therapeutic alternatives that might produce the

desired outcomes

• Selecting the drug recommendation that most likely will result

in the desired outcomes

• Establish a plan for therapeutic drug monitoring: documents

the desired effect occur and undesired effects are minimized

Strand, L.M., Cipolle, R.J. and Morley, P.C., “Documenting the clinical pharmacists activities: Back to basics,”

Drug. Intell. Clin. Pharm. 1988;22:63-67.

PWDT Step 4

Feasible

pharmacotherapeutic

alternatives for each DRP

Step 3

Desired

pharmacotherapeutic

Outcomes for each DRP

Step 5

Choose the best pharmaco

therapeutic

Solution and individualize

the therapeutic regimen

Step 6

Therapeutic drug

monitoring plan

Step 7

Implement the

individualized

regimen

And monitoring plan

Step 2

Patient specific DRPs Step1

Patient database

Step 9

Discharge summary

And communication

Step 8

Follow up

Pharmacist’s Patient Data Base Model

The daily care plan

Experience from Hamad General Hospital

Dr. Talal Nassar; B.Pharm. PharmD

MICU clinical pharmacist

HGH April, 24th. 2013

Objectives

• Explain the importance of documentation for a clinical

pharmacist

• Describe the elements of daily care plan

• Explain the need for daily clinical plan updating

• Explain how the daily clinical care plan updating will

help optimizing the therapeutic goals

• Explain the clinical and economic outcomes of daily

clinical plan updating

Documentation

• Pharmaceutical care is the direct,

responsible provision of medication-

related care for the purpose of achieving

definite outcomes that improve a patient’s

quality of life ¹

Documentation

• Documentation is a key for successful communication

between partners (clinical pharmacists)

• Ensure that the patient’s care is evident regarding

therapy, safety and quality

• Documentation translates the pharmacist’s follow up of

a patient’s case status

Documentation

• Reconciliation is a part of documentation

• Documentation is a rich source of

information for research or education

• Documentation and billing issues

Elements of daily care plan

• Patient’s care process starts by knowing your patient

and his/her case

• This process needs first to understand how to present

a case

• Then you need to understand how the MD think about

the case and what are his/her concerns


• What does a case presentation contain

Chief complain

Patient’s information

Demographic background: age, sex, race, weight, height, allergy

Family and social history

Disease information

HPI (time is very important)

PMH (time is very important)

PSH (time is very important)

Past medication history (reconciliation)


Review of systems

Physical examination

Vital signs: T, BP, HR, RR (SO2)

GEN, HEENT, NECK, CV, LUNGS, ABD, EXT, NEURO, PSYCH, SKIN, GU, Pelvic,

RECTAL, LYMPH, Mmsk

Lab results (chem7, CBC, ….)

Imaging studies (X-ray, CT, Echo, U/S…)

Current medications at ward

Assessment and plan


• After collecting these information and understand it, it is time to integrate it

Determine whether the treatment is appropriate, safe and

convenient for the patient in terms of your goals

Identify any drug-related problems that may interfere your

goals

Identify any potential drug-related problems that require

prevention

Keep in mind what and when do you expect results or side

effects from your treatment or adjusting therapy

Specify your follow up monitoring plan regarding therapy

The need for daily clinical updating

• The updating includes (not exclusive to)

Vital signs

Labs, cultures, …

Any new X-ray, CT, MRI, …

Any update in consultations (from other specialties and how this

will affect your therapy target)

Update patient’s medications (D/C, hold, delay in supply…) since

this may affect the time of your target or therapy goals

Update of IV fluids, In-Out, O2 requirements…

Update your monitoring parameters

The need for daily clinical

updating • Always ask on daily basis

• WHY

• DOES THE PATIENT NEED IT

• IS IT THE BEST TREATMENT

• WHAT I SHOULD DO NOW

» SHOULD I ADJUST DOSE

» SHOULD I DISCONTIUE, HOLD,

CHANGE or CONTINUE

The need for daily clinical

updating

• Monitor patient’ response including safety and effectiveness

• Follow up the improvement, if not why or worsening

• May change our care plan goals, therapeutic target…

• May ask for a new test, EKG…

• To prevent any worsening in a drug therapy if happens

• Full information for a research or education

• To take an appropriate action in appropriate time for any new

addressing problems

The daily clinical updating

• By updating clinical care daily

Optimize therapy according to patient’s status

Prevent or reduce problems

Reduce mortality and morbidity

Help other team members

Document interventions

Give an excellent picture about us as clinical pharmacists

which will reflects positively on our future

Economic outcomes of daily clinical

plan updating

• Remove unnecessary therapy

• May reduce cost by changing therapy ( IV to oral, IV

insulin to S/C …)

• Help reducing work load such as repeat

unnecessary labs (like HgA1C, TSH, Lipids…)

• Reduce morbidity and complications

• May reduce hospital stay

• May reduce re-admission

References

• American Society of Health-System Pharmacists. ASHP guidelines on documenting

pharmaceutical care in patient medical records. Am J Health-Syst Pharm. 2003; 60:705–7

• Pharmacotherapy- A Pathophysiologic Approach, 7th ed, 2008

• Appendix 4, Pharmaceutical care planning: The systemic approach.

http://www.scotland.gov.uk/Publications/2010/01/07144120/11

• Principles of Practice for Pharmaceutical Care. American Pharmacist Association.

http://www.pharmacist.com/principles-practice-pharmaceutical-care

Case discussion

• 52 years old Indian male brought to ER by EMS due to decrease of consciousness, weakness in the right part of the body. He has been admitted before 2 months due to AKI

PMH: DM II for the last 10 years, HTN for the last 7 years, A Fib for the last 3 years, CKD stage 2

PSH: no

FH: F and M (DM II), HTN, F had CAD at age of 52

SH: smoker for 20 years, no alcohol, no illicit

Medications history: warfarin 3 mg daily, insulin glargin 20 units pm, insulin lispro 5 units TID, amlodipine 10 mg

ROS: pt unconscious, no fever, no head trauma, no vomiting, move eye for pain stimuli, Palpitations, no wheezing, no swelling, no bedsore or rashes,

PE:

Vitals: BP 195/107, T 37.2, HR 127, RR 22, O2Sat 95% RA

HEENT: PERRLA

Chest: Lungs clear to auscultation bilaterally, pt intubated

CV: A fib, S1 +S2

Neuro: GCS 6, power LUE 0/5, LLE: 0/5, (hemiplegia)

Labs: normal but SrCr: 1.8 mg/dl, BG: 237 mg/dl, WBC: 13000,

CT shows hypodense area suggest hematoma, 2.6*1.7*2.1 seen in the posterior limb of the left internal capsule with minimal edema

Assessment: a case of DMII, HTN, A fib on warfarin, CKD 2, admitted due to ICH

Current medications: phenytoin 100mg IV tid, amlodipine 10 mg, esomeprazole 40mg, glargin 20 units, ceftriaxone 2 g BID IV

The Patient-Centered

Pharmaceutical Care Plan (PPCP)

Nadir Kheir, PhD


Implementing Pharmaceutical Care: Using a structured thought process for making

clinical decisions

Patient

Consultation

Assessment Care Plan &

Education

Monitoring &

Follow-up

Gauges patients’

concerns, beliefs,

desires of therapy

Understand

medication taking

behavior

Obtain med

history

Obtain current

med list

Document

Assesses entire

drug history,

looking for

actual or

potential DRPs.

Document

Develops care plans

to eliminate DRPs

and maximize

therapy outcomes.

Provide education

on use of medicine

Document

Monitors to assess

the progress

towards

therapeutic goals

Ensures that

new DRPs are

avoided, &

outcomes

evaluated.

Document


Care Planning in Pharmaceutical Care

1. The PCP is a patient-centered document that follows

patient consultation and assessment in the process

of Pharmaceutical Care (PC)

2. The content of a PCP are determined by the

information gathered and DRPs identified during the

assessment and consultation step

3. The PCP is usually formulated by the PC practitioner

separately and discussed with the patient afterwards


Care Planning in Pharmaceutical Care…

4. The PCP must be agreeable and comprehensible by

the patient

5. Monitoring/evaluation is conducted by the PC

practitioner with reference to the desired outcomes

articulated in the PCP (including clinical, laboratory,

humanistic and other outcomes)


Care Planning in Pharmaceutical Care…


Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: The clinician’s guide. 2nd Edition.

New York: McGraw Hill; 2004.

Summary: Foundations of a PCP

• The care plan organizes all the patient’s drug therapy and other interventions and help to optimize treatment

• The care plan includes measurable desired outcomes

• A care plan is developed as a result of analyzing all findings from the assessment process

• The care plan is organized by each medical condition (indication) and its pharmacotherapy (1 care plan per indication for drug therapy)

• The care plan must be negotiated with (and agreed for by) the patient

Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: The clinician’s guide. 2nd

Edition. New York: McGraw Hill; 2004.


The PCP:

• Includes strategies to improve compliance

• Includes interventions to improve drug therapy outcome, and eliminate (or prevent) drug therapy problems

• Includes advice on how to measure disease markers at home, when to seek medical help, and when to see the PC practitioner next

Accurate and detailed assessment results in relevant and successful care plan


Starting the Process

Establish therapeutic relationship:

- Meet and greet: introduce self (title, name)

- Explain the reason for the encounter, or ask for the patient’s reason (what can I do for you today?)

- Be structured, friendly, professional

- Prepare: time, information, background

- Prepared physical environment:

- Semi-private space

- Comfortable, professional, equipped

- No distraction

- Complete focus


Patient’s Own Description of Experience

• First step in the Consultation phase (after developing the therapeutic relationship)

• Information sought includes:

- what’s the patient attitude towards taking medicines (drugs don’t work, I don’t take meds)

- what does the patient expect/desires from therapy (needs vs. wants)

- any concerns (AEs, how to take meds and why)

- any cultural, religious, ethical issues that could affect the patient’s ability to take medication

Important starting point, allows you to plan

changes to influence patient’s attitudes PCPPD-7-Care Plan-2013-NK-AA-TN

History of

drug abuse

Concern of

bladder ca

History of

smoking

Duodenal

ulcer

Poorly controlled

Blood pressure

History of

Depression

Age &

Disability

?

Disease

Illness &

Concerns

Stroke

Shaking hands

From: Kheir N. Taped Consulting Session


Patient’s Medication Taking Behavior

Patient medication experience determines medication taking behavior (MTB)

MTB is the decision the patient makes in regards to the use of drug therapy

This has impact on whether:

- The patient takes the medication

- The patient stops taking a medication

- The patient refills a prescription

- The patient becomes fully compliant


Current Medication Record

All current health conditions and medications

Record for each drug

- generic & brand names

- indication

- dosage regimen: dose, frequency, duration

- how actually taken

- start day: checking temporal relationship in allergy, determine time to take effect

- response: stable, improved, partially improved, worsened, resolved, failed The process leads to analysis, identifying DRPs,

and Development of a Care Plan


PCP:

Activities & Responsibilities

Activity Responsibility

Establish goals of therapy Negotiate with the patient, agree on

desired outcomes, explain roles &

responsibilities

Determine interventions

to resolve or prevent

DRPs, and achieve

desired therapy outcomes

Discuss with patient, provide education

and training, use leaflets, contact other

healthcare providers, negotiate

interventions, advice on alternative

therapy and non-drug therapy

Schedule follow-up Agreed follow-up schedule to monitor

change and address any developing

issues

Adapted from: Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: The clinician’s

guide. 2nd Edition. New York: McGraw Hill; 2004.


Care Planning: 1. Determining Desired Goals of Therapy

• Goals of therapy must be set (for each condition) to

allow follow-up of care plan success

• Goals of therapy must be patient-centered

• Goals of therapy must be based on mutual agreement

and negotiation between the PC clinician and the patient

• Goals of therapy are based on clinical measurable or

observable indicators

• Multiple drug therapies for the same indication are

grouped together in the same care plan (i.e. 3 drugs

taken by the patient to treat hypertension)

•


Goals of Therapy as SMART Objectives

• Specific

• Measurable

• Achievable

• Realistic

• Time-bound

Each single

goal of

therapy must

be SMART

Subjective

outcomes are

measurable

from the

patient’s

description


General Goals of Therapy

• Curing a disease

• Eliminate signs and/or symptoms

• Slow progression of a disease

• Prevent a disease

• Normalize laboratory values

• Assist in the diagnostic process

Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: The clinician’s guide. 2nd Edition. New York:

McGraw Hill; 2004.


Goals of Therapy (Desired Outcomes)

What you are trying to

accomplish with

pharmacotherapy

How long it

will take

Time Frame

Improvements in clinical signs and

symptoms (observed values)

Changes in laboratory test results as

evidence of improvements (measured

values)

When to expect evidence

of improvement

Time required to achieve

full therapeutic response

Parameter


McGraw Hill; 2004.


The Skill to Decide Desired Outcomes

Usually, desired outcomes aim at:

• Approaching normal physiology (i.e., normalize blood

pressure)

• Slowing progression of disease (i.e., slow progression

of cancer)

• Alleviating symptoms (i.e., optimize pain control)

• Preventing adverse effects

• Educate the patient about his or her medication

• Improving compliance with drug regimen

• Applying life-style changes (promoting health) to

maximize benefits of drug therapy


Structure of Desired Outcomes

• Clinical parameter:

- observable, measurable, and realistic signs, symptoms and/or laboratory values

• A desired value or observable change in the parameter

• A specific timeframe in which the goal is to be met


McGraw Hill; 2004.


Examples of SMART Goals of Therapy

Medical Condition Goal of Therapy

Strep pneumonia, tuberculosis,

constipation

Cure of a disease

Depression, asthma Reduction or elimination of

signs and symptoms

Diabetes, hypertension,

dyslipidaemia

Slow or halt the progression of

disease

MI, osteoarthritis Prevent a disease

Anaemia, hypokalaemia Normalize lab values

See Table 8-4 (Goals of therapy for common medical conditions),

Cipolle et al, 2004; Establishing goals of therapy, pg 209-10)


Care Planning: 2. Making Interventions

• The purpose of interventions in the care

plan is to achieve goals of therapy, and

address DRPs

• All interventions are made with

consideration to:

- Measured and/or observed parameters

- Best practice & treatment guidelines

- Desired therapy outcomes


Making Interventions

• Each intervention (see next slide) is developed

and discussed with the patient, and other

significant others (who?)

• Each intervention is documented

• Each intervention should be expected to

help achieve desired outcomes (goals)


Care Plan: The SIX Interventions

• Initiate new drug therapy

• Increase dosages

• Decrease dosage

• Discontinue drug therapy

• Referrals

• Provide instructions for optimal use of

medications


McGraw Hill; 2004.


Discussing/Negotiating the Plan

• Discuss the action plan in a dedicated scheduled meeting

• Discuss each element in the plan

• Explain how each point would help the patient achieve specific desired outcome

• Be ready to alter the plan based on the patient’s preference while still achieving the desired outcomes

• Schedule a follow-up meeting to monitor (ensure timeframe is suitable to measure change)


Scheduling Follow-up and Evaluation

• Pre-set desired outcomes: clinical, lab, subjective

• Be clear what is required of the patient”

- Our next meeting should be in xx wks

- What date suits you the best?

- Can we contact you? Where?

- Do you have any issues you would like to discuss

about your care plan?


McGraw Hill; 2004.


The “Structure” of a Care Plan? Patient-Oriented Type of Care Plan



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A Demonstration:

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