THE P HARMACISTS WORKUP OF DRUG THERAPY

I. ASSESSMENT OF THE PATIENTS DRUG-RELATED NEEDS

REASON FOR THE PHARMACIST-PATIENT ENCOUNTER Patient Expectations
What does your patient want? What are your patients expectations of his/her medications? Are they realistic, achievable? Does your patient expect to be an active participant in the management of his/her pharmaceutical care?

Patient Concerns
What concerns does your patient have about his/her health in general, medical conditions or drug therapies? What concerns does your patient have about side effects, toxicity, allergies, costs?

Patient Understanding of Drug Therapy

What is your patients level of understanding of his/her diseases, drug therapies and instructions? Does your patient understand that it will be necessary to actively participate in his/her care?

PATIENT BACKGROUND
Age Gender Race Ht Wt LBW
Male = 50kg + [2.3 x (no. inches > than 5'0")] Female = 45kg + [2.3 x (no. inches > than 5'0")]

Family
Describe your patients family children? how many? ages? Does your patient live with his/her Parents? Does your patient have a family history of certain diseases, conditions or risk factors for drug therapy problems?

Living Arrangements
Who lives with your patient? Who cares for your patient? Does your patient live alone? Who administers medications?

Occupation
Describe the socioeconomic status of your patient. Does employment put your patient at risk for certain diseases or drug therapy problems? Insurance plan and coverage.

Primary physician or clinic

Is there one primary physician? More? What type of relationship does patient have with physician? What information does your patient share with physician about drug therapy?

Health Plan
What type of payment system does the patient have? How will this affect decisions about the patients drug therapy?

MEDICAL CONDITIONS
List all of your patients current (active) medical conditions and their associated drug therapies beginning with the primary presenting condition (or reason for the encounter) and continuing in order of priority of need or want for the patients remaining conditions. When did the present primary condition(s) begin and what has been the course of the patients illness (symptomatology) over the recent past? Has the present medical problem been treated with drugs previously? What was the outcome? Are these conditions being managed with medications? Are all medical problems being appropriately treated? Do any of these medical problems suggest an indication for additional or new drug therapy? Are any of these conditions the result of drug therapy, or could they affect the
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way drugs are absorbed, distributed, metabolized, or eliminated by your patient? Describe important past medical events, surgeries, or traumatic events that may impact decisions about your patients drug therapy. The drug therapies associated with each of the patients medical conditions needs to be assessed to ensure that each is as effective as possible and as safe as possible.

OTHER MEDICATIONS
Identify all additional medications presently taken by your patient as well as those taken during the past six months including prescription, physician samples, non-prescription (OTC), as well as herbal remedies or alternative therapies. These therapies also need to be assessed to ensure that they are appropriately indicated, as effective as possible, as safe as possible and convenient enough for the patient to take as directed.

ALERTS
ALLERGIES and ADVERSE DRUG REACTIONS:
Have any allergic reactions occurred in the past? What is the nature and significance of past allergic reactions? Do potential allergies exist (drug, food, preservatives, additives, etc.)? Is there evidence that the patient could not tolerate a medication or d osage form in the past due to an adverse drug reaction? What concerns does your patient have about their drug allergies or reactions? Pay particular attention to allergic symptoms that are common during infancy and childhood including: eczema, urticaria, perennial rhinitis and reactions to insect bites. Does patient have or need a medical alert bracelet or tag?

IMMUNIZATION HISTORY Are your patients immunizations up to date including diptheria, tetanus, pertussis, Haemophilus Influenzae type b, poliovirus, measles, mumps, rubella, Hepatitis B, Varicella Zoster? SMOKING/ALCOHOL/RECREATIONAL DRUG USE:
Describe the tobacco, alcohol, or caffeine use of your patient. Does it contribute to the patient's medical problems of health risks in general? Does it affect drug absorption, distribution, metabolism, or elimination?

COMPLIANCE HISTORY
Who is responsible for medication administration for your patient? Is there evidence that your patient has any difficulty understanding and complying with medication instru ctions?

SPECIAL NEEDS
What unique needs does your patient have that will need to be accommodated when designing a personalized pharmaceutical care plan? For example, physical abilities, allergies, cultural traits, health care beliefs. Are there needs for labeled instructions, child -proof tops, drug administration devices, compliance reminders, taking medications at work/school?

REVIEW OF SYSTEMS
The primary purpose of the review of systems is to identify any other or additional drug-related needs. Make your own observations and include your findings, your interpretation of any abnormal or unexpected findings, as well as any required baseline values to be used as comparisons for later follow-up evaluations.

EENT Does the patient have a streptococcal sore throat, cough, cold, otitis media, allergic rhinitis,
conjunctivitis, cold sores, glaucoma, hearing loss, thrush, dental infection, dental pain? Does your patient need vision correction? Does your patient have difficulties with contact lenses, ophthalmic drops, or ointments? Would your patient benefit from a vaporizer or humidifier?

GASTROINTESTINAL Does your patient have a peptic ulcer disorder? Is the condition of your patient's GI
system (ulcer, stress ulcer, esophagitis, gastritis, diarrhea, constipation, Crohns disease, ulcerative colitis) require
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treatment or is it being caused by medications your patient is taking? Is your patient's GI dysfunction (nausea, vomiting, diarrhea) affecting drug absorption or bioavailability?

PULMONARY
Does your patient have pulmonary dysfunction (asthma, pneumonia, bronchitis, sinusitis, influenza, COPD, pulmonary embolism) which may contraindicate the use of certain drugs? Is the pulmonary function compromised by drugs your patient is receiving?

CARDIOVASCULAR
Is your patient experiencing side effects from drugs manifested in the cardiovascular system (hypertension, dysrhythmias, tachycardia, bradycardia, angina pectoris, congestive heart failure, hyperlipidemia )? Is your patient receiving drug therapy that might cause orthostatic hypotension, dizziness, or falling? Is your patient's cardiovascular dysfunction affecting drug absorption, distribution, metabolism or elimination?

HEMATOLOGY Does your patient have anemia? Does your patient require iron and or folic acid supplements?
Are coagulation studies needed to determine liver functions and/or therapeutic endpoints for anticoagulation [baseline status]? Are there abnormalities in red blood cell, white blood cell, or serum proteins that may be caused by drugs your patient is receiving? Are any hematological parameters abnormal require follow-up evaluation?

ENDOCRINE Does your patient have diabetes, hypothyroidism, hyperthyroidism? Are any of the drugs your
patient is taking affecting endocrine functions (glucose, thyroid, menstrual bleeding/ menopause, glucose control?) Does your patient's glucose require frequent evaluation?

HEPATIC Are any drugs producing toxic effects in the liver? Is your patient's hepatic function affecting drug
elimination?

RENAL Does your patient have a urinary tract infection? Is your patient receiving drug(s) that can impair renal
function? Is your patient's renal function affecting the elimination of certain drugs? Do you need to adjust drug dosing due to poor function?

CrCl = (140-age) x LBW = SCr x 72

ml/min

{CrCl femaled estimated as CrCl males x 0.85}

GU/REPRODUCTIVE Does your patient require estrogen replacement therapy? Is the condition of your patient's
GU system (prostatitis, vaginitis, endometriosis, dysmenorrhea, osteoporosis, incontinence) require treatment or is it being caused by medications your patient is taking? Is your patient experiencing impotence secondary to drug therapy? Are drugs being taken during pregnancy or lactation? Could your patient benefit from contraceptive product, advice or referral?

MUSCULOSKELETAL Does your patient have pain requiring drug therapy (back pain, tendonitis, sports injury,
muscle spasm)? What is the type and location of pain? What medication(s) does your patient take for pain, arthritis pain, rheumatoid arthritis, osteoarthritis, or headaches? Could your patient benefit from external analgesics, ice packs, or heating pads? Does your patient suffer from multiple sclerosis? Does your patient have gout?

SKIN Does your patient have dermatitis, eczema, psoriasis, acne, wound infection, skin infection, rash? Is your
patient using any topical medications? Is the dermatological disorder being caused by drugs your patient is receiving? Would your patient benefit from sunscreen protection?

NEUROLOGICAL Does your patient have include a seizure disorder, epilepsy, migraines, stroke, TIA,
disorientation to person-place-time, memory loss, dementia, Alzheimer's Disease, dizziness? Does this condition compromise your ability to evaluate outcomes of drug therapy or adverse drug reactions? Is your patient experiencing a neurologic abnormality (confusion, drowsiness) resulting from drug therapy? Is your patient's neurologic status affecting his/her ability to understand or adhere to instructions?

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PSYCHOLOGICAL Does your patient have major depression requiring drug therapy? Does your patient suffer
from anxiety, schizophrenia, panic disorder, attention deficit disorder? Is your patient experiencing a psychological abnormality resulting from drug therapy? Is your patient's psychological status affecting his/her ability to adhere to required drug regimens? Does your patients history or background include a psychological condition (memory loss, thought content, mood, anxiety, depression, confusion, delirium, insomnia) that might compromise your ability to evaluate outcomes of drug therapy or adverse drug reactions?

FLUID/ELECTROLYTE STATUS
Does your patient require vitamin or nutritional supplements? Is your patient experiencing side effects from certain drugs manifested as fluid & electrolytes disturbances? Is this affecting drug absorption, distribution, metabolism, or elimination? Does your patient need potassium supplements? Calcium supplements?

VITAL SIGNS
Are there deviations from normal which could be due to drug therapy? Are there deviations from normal which should be incorporated into the plan for follow-up evaluations of drug therapy? Temperature Heart Rate Blood Pressure Respiratory Rate

DETERMINE IF THERE ARE DRUG THERAPY PROBLEM(S) TO BE RESOLVED, OR PREVENTED AND DESCRIBE THE DRUG THERAPY PROBLEMS (C ONDITION, DRUG AND REGIMEN, AND ASSOCIATION)

ASSESSMENT
APPROPRIATE INDICATION

DRUG THERAPY PROBLEM

Needs Additional Drug Therapy __Untreated condition __Synergistic/potentiating __Preventive/prophylactic Unnecessary Drug Therapy __No medical indication __Addictive/recreational __Non drug therapy indicated __Duplicate therapy __Treating avoidable ADR

ASSESSMENT
SAFETY

DRUG THERAPY PROBLEM

Adverse Drug Reaction __Unsafe drug for patient __Allergic reaction __Incorrect administration __Drug interaction __Dosage change too rapid __Undesirable effect Dose Too High __Wrong Dose __Frequency inappropriate __Duration inappropriate __Drug interaction Not Following Instructions __Drug product not available __Can not afford drug product __Can not swallow / administer __Directions not understood __Patient prefers not to take __Other reasons

EFFECTIVENESS Wrong Drug

__Dosage form inappropriate __Contraindications present __Condition refractory to drug __Not indicated for condition __More effective drug available Dosage Too Low __Wrong dose __Frequency inappropriate __Duration inappropriate __Incorrect storage __Incorrect administration __Drug interaction

APPROPRIATE COMPLIANCE

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SUMMARIZE YOUR ASSESSMENT OF YOUR PATIENTS DRUG RELATED NEEDS AND DRUG THERAPY
PROBLEMS

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II.

THE CARE PLAN

MEDICAL CONDITION
In the care plan, organization is important, therefore each medical condition is to be addressed comprehensively, yet separately. This organization is useful in order to keep associated drug therapy problems, goals of therapy, interventions, and outcomes organized appropriately.

DRUG THERAPY PROBLEMS TO RESOLVE OR PREVENT Statement of the drug therapy problems to be resolved or prevented
State your patients drug therapy problem. Drug therapy problems include: 1) the patients problem or condition 2) the drug involved and 3) the association between the drug and the patient's problem. State the goal for successful resolution of the drug therapy problem.

Options to resolve or prevent your patients drug therapy problem

For each drug therapy problem, list the drug regimen(s) or changes in your patients drug regimens

that might be expected to resolve the drug therapy problem(s).

Interventions to resolve or prevent your patients drug therapy problems

What interventions and actions designed to resolve your patients drug therapy problems. For each drug therapy problem document recommendations made to the patient (or patient's caregiver) or on the behalf of the patient to the prescriber (physician, dentist, nurse practitioner.

GOALS OF THERAPY STATE THE GOALS OF THERAPY

Establish therapeutic goals for each of your patients medical conditions: Format: Goals are stated in the future tense, for example, "the patient will achieve, maintain...," or "infection will be cured within 7 days, or disease, signs or symptoms will be eliminated or reduced within 30 days. Therapeutic goals should be measurable, observable, specific, and have a definite time frame.

ALTERNATIVES TO ACHIEVE THE GOALS OF THERAPY

These are the various choices of drug products and dosage regimens that could realistically achieve the goals of therapy. Agents are considered a viable therapeutic alternative primarily based on potential to be effective. Priority is given to agents that have demonstrated efficacy for the medical condition. Secondarily, safety, convenience and cost issues are considered.

INTERVENTIONS TO ACHIEVE GOALS OF THERAPY

The interventions represent the decisions made and work actually performed by the practitioner to achieve the established goals of therapy. For each medical condition, document recommendations made to the patient (or patient's caregiver) or on the behalf of the patient to the prescriber (physician, dentist, nurse practitioner). Format: Interventions are stated in the past or present tense, and describe the decisions made as to what drug products, dosage regimens, drug information, or health advice is provided to manage the patients medical condition.

FOLLOW-UP PLAN AND SCHEDULE

Follow-up consists of a scheduled (when) encounter (face to face or telephone) with the patient, which is designed to gather information to determine to what extent the recommended care plan is producing the desired effect(s), achieving goals of therapy, and not resulting in undesirable or intolerable side effects.

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III.

FOLLOW-UP EVALUATION
EVALUATE ACTUAL PATIENT OUTCOMES
Each follow-up evaluation contains your clinical judgment as to how effective the care plan and the associated drug therapies have been in achieving the goals of therapy for each of your patients medical conditions. From the information gathered at the follow-up evaluation, you evaluate the actual outcomes and document the progress (or lack of progress) in achieving the goals of therapy. The status of each medical condition being managed by medications is evaluated at each follow-up encounter. The status of each medical condition being managed by drug therapy can be described as resolved, improved, partial improvement, stable, not improved, worsened, failure, or expired. The definition of the outcome status terms contain a clinical decision and an action on the part of the practitioner.

STATUS
Resolved Stable Improved Partially Improved Unimproved Worsened Failure Expired

DEFINITION
Goals of therapy have been achieved, drug therapy has been completed or can now be discontinued. Usually associated with therapy for an acute disorder. Goals of therapy have been achie ved. The same drug therapy will be continued. Usually associated with therapy for a chronic disorders Adequate progress is being made towards meeting the goals of therapy at this point in time and the same drug therapy will be continued. Some measurable progress is being made towards achieving the desired goals of therapy, yet adjustments in drug therapy are required. Usually dosage changes or the addition of additive or synergistic therapies are required. No measurable progress in achieving goals of therapy can be demonstrated at this time, but it is judged that more time is needed to produce adequate response. Will continue with the same drug therapy. There has been a decline in health status while receiving the current drug regimen and adjustments in drug dosage or product selection are required. The goals of therapy have not been achieve despite best efforts with the current drug regimen. Discontinuation of the present medication and initiation of new drug therapy is required. Patient died despite best efforts to manage the medical condition the drug therapy.

REASSESS AND EVALUATE PATIENT FOR NEW DRUG THERAPY PROBLEMS.

The practitioners clinical judgment as to whether the patient has developed new drug therapy problems since the previous assessment.

SCHEDULE FOR NEXT FOLLOW- UP EVALUATION

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