Section I

PHARMACEUTICAL CARE AND

THE SCOPE OF PHARMACY PRACTICE

I. INTRODUCTION
1. The Practice of Pharmacy embraces a variety of settings, patient
populations, and specialist as well as generalist pharmacists. Central to the
practice of pharmacy, however, is the provision of clinical services directly
to, and for the benefit of patients.
2. Definition. The term Pharmaceutical care describes specific activities and
services through which an individual pharmacist cooperates with a
patient and other professionals in designing, implementing and monitoring a
therapeutic plan that will produce specific therapeutic outcomes for the
patient.
II. SCOPE OF PRACTICE WITHIN PHARMACEUTICAL CARE
1. Role. Pharmaceutical care has evolved from an emphasis on prevention of
drug- related problems (basically drug management) to extend roles of
pharmacists in the Triage of patients, treatment of routine acute illnesses,
management of chronic diseases, and primary disease prevention.
2. Function. The provision of pharmaceutical care does not imply that the
pharmacist is no longer responsible for dispensing functions. In many
instances, however, implementation of pharmaceutical care services
necessitates a redesign of the professional work flow, with assignment of
technical functions to technical personnel under the direct supervision and
responsibility of the pharmacist.
III. UNIQUENESS OF PHARMACEUTICAL CARE
Provision of pharmaceutical care overlaps somewhat with other
aspects of pharmacy practice (Table 1). However, pharmaceutical
care is not the same as these other areas, which include:
1. Clinical Pharmacy
2. Patient counseling
3. Pharmaceutical services; when the activities of a pharmacy or pharmacy
department are performed for faceless patients or charts, the activity is
one of pharmacy service, not pharmaceutical care (e.g., chart or drug

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 profile reviews without input from the patient or care giver is not
pharmaceutical care).

Table 1 UNIQUENESS OF PHARMACEUTICAL CARE

Traditional Clinical Pharmacy Pharmaceutical

Pharmacy Care
Primary Prescription order or Physicians or other Patient
Focus OTC request health professionals
Continuity Upon Demand Discontinuous Continuous
Strategy Obey Find fault or Anticipate or
prevention improve
Orientation Drug product Process Outcomes

IV. ESSENTIAL COMPONENTS OF PHARMACEUTICAL CARE

A. Pharmacist patient relationship
The importance of putting a face and personality with the clinical picture is
a key component of pharmaceutical care. A pharmacist can have a caring
relationship with a patient but not with a chart or drug profile. A pharmacist
cannot have empathy for words on a page or on a computer screen.
Pharmaceutical care is based upon a collaborative effort between
pharmacist and patient.
B. Pharmacists workup of drug therapy (PWDT)
The provision of pharmaceutical care is often centered around process
described as the PWDT. Although the forms or methods used for this
process may vary, the components are essentially the same.
1. Data collection. Collect, synthesize, and interpret relevant information
such as:
1. Patient demographic data: age, sex, and race.
2. Pertinent medical information
(1) Current and past medical history
(2) Family history
(3) Social history
(4) Dietary history
(5) Medication history ( prescription , OTC, social drugs and
allergies)
(6) Physical findings (e.g., weight, height, blood pressure, edema)
(7) Laboratory or other test results (e.g., serum drug levels,potassium
level, serum creatinine as relevant to drug therapy)

3. Patient complaints, symptoms, signs.

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2. Develop or identify the CORE Pharmacotherapy Plan
1. C Condition or patient need
2. O Outcomes desired for that condition
3. R Regimen selected (prescribed) to achieve that outcome
4. E Evaluation parameters to assess outcome achievement

3. Identify the PRIME pharmacotherapy problems or indications for

pharmacist interventions. The goal is to identify actual or potential
problems that could compromise the desired patient outcomes (Table 2).
1. P Pharmaceutical based problems
2. R - Risks to patient
3. I Interactions
4. M Mismatch between medication and condition or patient needs.
5. E Efficacy issues

4. Formulate a FARM progress note to describe and document the

interventions intended or provided by the pharmacist.

1. 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.

2. A Assessment: the pharmacists evaluation of the findings,

including a statement of:
(1) Any additional information that is needed to best assess the
problem in order to make recommendations.
(2) The severity, priority, or urgency of the problem.
(3) The short-term and long-term goals of the intervention
proposed or provided
1. Examples of short-term goals include: eliminate
symptoms, lower blood pressure (BP) to 140/90 within
6 weeks, manage acute asthma flare up without
requiring hospitalization.
b. Examples of long-term goals include: prevent
recurrence, maintain BP at less than 135/80, prevent
progression of diabetic nerve disease.

c. R- Resolution (including prevention): the intervention plan

includes actual or proposed actions by pharmacist or
recommendation to other health care professionals. The rationale
for choosing a specific intervention should be stated.
Intervention options may include:
(1) Observation, reassessing, or following: no intervention
necessary at this time. If no action was taken or recommended, the

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 FARM note serves as a record of the event and should constitute
part of the patients pharmacy chart or database.
(2) Counseling or educating the patient or care giver
(3) Making recommendations to the prescriber
(4) Informing the prescriber
(5) Making recommendation to the prescriber
(6) Withholding medication or advising against use

d. M Monitoring and follow-up: the parameters and timing of

follow-up monitoring to assess the efficacy, safety, and outcome
of the intervention. This portion of the FARM note should include:
(1) The parameter to be followed (e.g., pain, depressed mood, serum
potassium level)
(2) The intent of the monitoring ?(e.g, efficacy, toxicity, adverse
event)
(3) How the parameter will be monitored (e.g, interview patient,
serum drug level, physical examination)
(4) Frequency of monitoring (e.g, weekly, monthly)
(5) Duration of monitoring (e.g, until resolved, while on antibiotic,
until resolved then monthly for one year)
(6) Anticipated or desired finding (e.g, no pain, euglycemia, healing
of lesion)
(7) Decision point to alter therapy when or if outcome is not achieved
(e.g., pain still present after 3 days, mild hypoglycemia more than
2 times a week)

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Table 2 PRIME PHARMACOTHERAPY PROBLEM TYPES

Pharmaceutical Assess for incorrect

Dose
Route
Duration
Form
Frequency
timing
Risks to Patient Assess for
known contraindication
patient medication allergy
drug-induced problem
improper utilization (i.e., risk is misused)
common/serious adverse effects
medication error considerations
Interactions Assess for
drug-drug
drug-food
drug-disease/ condition
drug-lab
Mismatch between Assess for
medication and medication used without indication
indications/ conditions/ indication, condition, or complaint
complaints untreated
Efficacy issues Assess for
suboptimal selection of pharmacotherapy
for indication
minimal or no evidence of therapeutic
effectiveness
suboptimal utilization of pharmacotherapy
(taking or receiving medications incorrectly)
-patient preference consideration (e.g.,
undesirable prior experiences with
medication , does not believe works)
-medication availability considerations
-compliance or administration
considerations (e.g., inability to pay,
unable to administer correctly or at all)

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V. CLINICAL SKILLS AND PHARMACISTS ROLES IN PHARMACEUTICAL
CARE
The skills activities and services inherent in the provision of pharmaceutical
care include, but are not limited to, the following:

1. Patient assessment
1. Physical assessment
2. Barriers to adherence
3. Psychosocial issues

2. Patient education and counseling

1. interview skills
2. communication skills (e.g., empathy, listening, speaking or writing at
the patients level of understanding)
3. ability to motivate, inspire
4. develop and implement patient education plan based on an initial
education assessment
5. identification and resolution of compliance barriers

3. Patient- specific pharmacist care plans

1. recognition, prevention, and management of drug interactions
2. pharmacology and therapeutic (innovative and conventional)
3. interpretation of laboratory tests
4. knowledge of community resources, professional referrals
5. communication and rapport with community medical providers

4. Drug Treatment protocols

1. develop and maintain (update) protocols
2. follow protocols as o pharmacist clinician
3. monitor aggregate adherence to treatment protocols (e.g., drug
utilization evaluations {DUE} ) especially for managed care or health
system facility.

5. Dosage adjustment
1. Identify patients at risk for exaggerated or subtherapeutic response.
2. Apply pharmacokinetic principles to determine patient-specific dosing
3. Order and interpret relevant tests at correct time intervals to assess
dosage adjustment (e.g., plasma drug concentrations, blood glucose
levels, blood pressure measurements)

6. Selection of therapeutic alternatives

1. use drug information resources effectively
2. review and critique drug literature
3. construct comparative analyses to support therapeutic decisions

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 7. Prescriptive authority in designated practice sites or positions

H. Preventive services
1. Immunizations
2. Screenings
3. Health and wellness education

I. Managerial skills
1. plan, direct and implement pharmaceutical care activities within various
practice environments, such as community pharmacy, ambulatory care
settings, managed or contractual care, home health services, long-term
care facilities, inpatient hospital practice, and others.
2. Allocate resources.

VI. PHARMACEUTICAL CARE AS THE MODEL FOR PHARMACY

PRACTICE
The concepts, activities,, and services of pharmaceutical care form the
basis for provision of clinical services directly to, and for the benefit of
patient in all pharmacy practice settings. These settings include home
health, hospital, ambulatory care, primary care, consultation, long term
care, and community pharmacy practice. Workflow, staffing patterns,
processes, and pharmacy programs might differ, but the core approach to
patient care remains pharmaceutical care in all settings. Figure 1 &
Figure2 illustrate pharmaceutical care models in the institutional and
community pharmacy settings.

VII. Documentation of Pharmaceutical Care

Documentation of pharmaceutical care is integral to continuity of
care, demonstration of clinician competence, communication among
health care providers, evidence of contributions to patient care, and
reimbursement of professional services.

1. Pharmaceutical care, including the Pharmaceutical care plan process

(CORE, PRIME & FARM), is a systematic method for recording the
pharmacists examination of a patient pharmacotherapy and subsequent
identification of medication-related problems.

2. In most practice settings, computer software programs maintain patient data

and drug profile records. Thus, after documentation of the initial
pharmaceutical care plan, patient data or drug regimens are included in
subsequent FARM notes only if a change occurs that is relevant to the
therapeutic issue being addressed in the note.

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3. Forms that summarize pharmacists interventions using a unified coding
system are useful for processing reimbursement of billing forms, but these
forms are not adequate documentation of pharmaceutical care. These forms
do not communicate to other health professionals the depth and quality of
pharmacist interventions or the pharmacists plan for ongoing
pharmaceutical care.

VIII. Pharmaceutical Care : An ongoing process

The patient profile is revised and re-assessed each time a new drug
is added to or deleted from the medication regimen, a new disease
or condition is diagnosed, or the patient undergoes other clinical
intervention, such as surgery. When the patient returns to the
pharmacy or is readmitted to the health system facility, the
pharmacist uses the patient profile, PWDT, and FRAM notes
(maintained in the patient pharmacy chart or in the medical chart) as
the basis for ongoing pharmacists-patient interactions.

XI. IMPORTANCE OF PHARMACEUTICAL CARE IN TODAYS PHARMACY

PRACTICE

1. The potential for medication errors is growing, and one professional group
must assume a primary role in addressing this issue rather than fragmented
efforts by various groups or individuals. The pharmacist is trained
specifically to address these therapeutic issues.
1. The use of prescription and nonprescription medications is growing and
now constitutes the primary therapeutic modality available to health care
practitioners and patients.
2. The number, complexity, and potency of prescription and non
prescription drug products is increasing.

2. The need for pharmaceutical care secures an enduring role for the
pharmacist in the American health care system. Every encounter with
patients, regardless of practice setting, provider pharmaceutical care.

3. Pharmaceutical care activities integrate pharmacists into the health care

system of the future.

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Figure 1 - TEMPLATE FOR PHARMACEUTICAL CARE : INSTITUTIONAL
PRACTICE

Data Collection
1. Review patient medical record
2. Review medication profile
3. Interview patient

Develop or identify the CORE

Pharmacotherapy Plan

Key Points 1. Individual dosing

1. 2. Medication without indication
Focus on outcomes, not interventions 3. Indication without medication
Identify drug related problems or 4. Potential or actual allergy or ADR
patient needs (PRIME) 5. Drug-drug/ lab/ food interaction
6. Optimal drug selection
2. Daily pharmacy rounds are important 7. Pharmacokinetics
Pharmacists can make rounds 8. Education
without medical team 9. Potential cost saving (IV or PO, etc)
3. Use this approach with all clinical
Formulate a Pharmaceutical
programs, Plan includes such
Care Plan
as Findings
pharmacokinetic Assessment
Resolution/
dosing, disease management clinics, recommendation
Monitoring

Communicate Plan with patient,

clinical pathways, etc
health care team, etc

Document actions taken in patient

medical record