7 CPPD-Care Planning NK AA 24apr13 Pres PDF

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
PCPPD-7-Care Plan-2013-NK-AA-TN
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…
• The development of a PPCP can be summarized as a five
step process involving the SOAP format
Step 5.
Step 1. Step 2. Step 3. Step 4.
Evaluating
Gathering Identifying Assessing Developing
Achievement
Information Problems Problems the Plan
of Outcomes
NAPRA. Developing a Pharmaceutical Care Plan. 2007.
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.
PCPPD-7-Care Plan-2013-
NK-AA-TN
The “Structure” of a Care Plan?
History of Documenting a Pharmaceutical
Care Plan
Documenting a Care Plan
SOAP Subjective Objective Assessment Plan

Note
FARM Finding Assessment Recommend Monitoring

Note
DAP Data Assessment Plan

Note
DRP DRP Recommend Plan

Note
Documenting a Care Plan…
SOAP Format
Subjective Objective Assessment Plan
Expanded – SOAP Format

Subjective Objective Assessment Plan Goals Monitoring Education
HOAP Format
History Observation Assessment Plan
Hurley SC. A Method of Documenting Pharmaceutical Care Utilizing Pharmaceutical Diagnosis. AJPE.
1998;68:119-127.
Documenting a Care Plan…
SOAPIER Format
Subjective Objective Assessment Plan Implement Evaluation Revision
DAR Format
Data Action Response
FARM Format
Findings Assessment Resolution Monitoring
1998;68:119-127.
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
The SOAP Note…
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
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)
The SOAP Note…
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.
The SOAP Note…
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
Systematic Approaches to Care Planning
PPCP
• Pharmacist’s
PMDRP • Care
• Plan
• Pharmacist’s
PWDT • Monitoring of
• Drug
• Pharmacist’s
• Related
• Workup of
• Problems
• Drug
• Therapy
1998;68:119-127.
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.
Step 2
Patient specific DRPs Step 3
Step1 Desired
Patient database pharmacotherapeutic
Outcomes for each DRP
Step 9 Step 4
Discharge summary Feasible
PWDT
And communication pharmacotherapeutic
alternatives for each DRP
Step 8 Step 5
Follow up Choose the best pharmaco
therapeutic
Solution and individualize
the therapeutic regimen
Step 7
Implement the Step 6
individualized Therapeutic drug
regimen monitoring plan
And monitoring plan
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 Assessment Care Plan & Monitoring &
Consultation Education Follow-up
Gauges patients’ Assesses entire Develops care plans Monitors to assess

concerns, beliefs, drug history, to eliminate DRPs the progress
desires of therapy looking for and maximize towards
therapy outcomes. therapeutic goals
 Understand actual or
Provide education
medication taking potential DRPs. on use of medicine
Ensures that
behavior Document new DRPs are
Document avoided, &
 Obtain med
history outcomes
evaluated.
Obtain current
med list Document
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
Illness &
Concerns
Disease
Concern of
bladder ca
Poorly controlled
Blood pressure
History of
smoking
Duodenal
ulcer
History of
Depression Stroke
History of Shaking hands

drug abuse
Age &
Disability
?
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 Discuss with patient, provide education
to resolve or prevent and training, use leaflets, contact other
DRPs, and achieve healthcare providers, negotiate
desired therapy outcomes 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 Each single

goal of
• Measurable therapy must
be SMART
• Achievable
• Realistic Subjective
outcomes are
• Time-bound 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 How long it
pharmacotherapy will take
Parameter Time Frame

Improvements in clinical signs and
symptoms (observed values) When to expect evidence
Changes in laboratory test results as of improvement
evidence of improvements (measured Time required to achieve
values) full therapeutic response
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, Cure of a disease
constipation
Depression, asthma Reduction or elimination of
signs and symptoms
Diabetes, hypertension, Slow or halt the progression of
dyslipidaemia 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:
Filled Form
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THANK YOU
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Continuing Professional Pharmacy Development Program

Care Planning in Pharmacy

Ahmed Awaisu, PhD

NAPRA. Developing a Pharmaceutical Care Plan. 2007.

NAPRA. Developing a Pharmaceutical Care Plan. 2007.

• A systematic way of practice

SOAP Subjective Objective Assessment Plan

FARM Finding Assessment Recommend Monitoring

DAP Data Assessment Plan

DRP DRP Recommend Plan

Expanded – SOAP Format

Dr. Talal Nassar; B.Pharm. PharmD

• Pharmaceutical care is the direct,

responsible provision of medication-

related care for the purpose of achieving

definite outcomes that improve a patient’s

• 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

• Reconciliation is a part of documentation

• Documentation is a rich source of

information for research or education

• Documentation and billing issues

• Patient’s care process starts by knowing your patient

and his/her case

• This process needs first to understand how to present

• Then you need to understand how the MD think about

the case and what are his/her concerns

 Lab results (chem7, CBC, ….)

 Any new X-ray, CT, MRI, …

 Any update in consultations (from other specialties and how this

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

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

 Update your monitoring parameters

• DOES THE PATIENT NEED IT

• IS IT THE BEST TREATMENT

• WHAT I SHOULD DO NOW

» SHOULD I ADJUST DOSE

» SHOULD I DISCONTIUE, HOLD,

 Prevent or reduce problems

 Reduce mortality and morbidity

 Help other team members

 Give an excellent picture about us as clinical pharmacists

• Remove unnecessary therapy

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

• Help reducing work load such as repeat

• Reduce morbidity and complications

• May reduce hospital stay

• May reduce re-admission

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

Nadir Kheir, PhD

Gauges patients’ Assesses entire Develops care plans Monitors to assess

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

4. The PCP must be agreeable and comprehensible by

Accurate and detailed assessment results in

History of Shaking hands

 Patient medication experience determines

 All current health conditions and medications

Establish goals of therapy Negotiate with the patient, agree on

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