A pharmacist may review a patient's overall medication requirements to ensure the effective use of medicine, following a diagnosis(es) made by another health care professional, in order to maximise therapeutic outcomes. A review of the patient's overall medication requirements involves analysing the patient's medication record to assess the appropriateness and cost-effectiveness of treatment to ensure rational drug use, and to identify possible interactions and adverse drug reactions. It also involves developing a plan of action in collaboration with other health care professionals and the patient as well as the necessary follow-up. Such a review may involve a consultation with the patient. Full records must be kept.
The responsibility of the pharmacist who provides such a review is to care for a patient's medicine-related needs by making sure that all of a patient's medicine therapy is appropriate, the most effective available, the safest possible and is used as indicated. This is accomplished by identifying, resolving and preventing medicine therapy problems that could interfere with meeting a patient's medicine therapy goals successfully and producing positive patient outcomes.
It is not necessary to provide an overall review of all patients' medication requirements every time they visit a pharmacy. Situations that would justify such a review are any of the following:
| (a) | a patient with a new prescription; |
| (b) | patients on chronic therapy, depending on the disease, the medicines prescribed, and the patient's needs; |
| (c) | situations where a medicine therapy problem is identified and/or a potential medicine-related problem is anticipated to occur in the future; |
| (d) | the patient has questions regarding his or her medicine therapy, concerns about an adverse drug reaction or requests a review of his/her medication. |
A patient can request a review of his/her medication by asking the pharmacist for help with regard to a medicine-related problem. Another health care provider, for example a medical practitioner, nurse, dentist or another pharmacist, might refer a patient for a medication review or a pharmacist's assistant or another pharmacist dispensing medicine to a patient might identify some need for care.
The review process must be systematic, structured, ongoing and documented. It consists of three important steps:
| (a) | an assessment phase (start care, work-up, assessment) where the pharmacist assesses the patient's medicine-related needs, including the identification of any medicine therapy problems that exist, or need to be prevented in the future; |
| (b) | the development of a care plan (care planning, interventions) by the pharmacist and patient in consultation with the prescriber (as necessary), together with goals of medicine therapy and appropriate interventions; and |
| (c) | a follow-up evaluation to determine the actual patient outcomes that have resulted from the care provided. |
Where a pharmacist performs an overall review of the patient's medication, the following standards are applicable:
| 2.25.1 | Patient information/database |
Regardless of the practice environment, a common set of information should be collected for each patient. The following information should be included in a comprehensive pharmaceutical care database:
| (a) | Demographic data including the patient's name, date of birth, gender, height, weight, body weight index, ethnic group, address, phone number, health care providers, (for example medical practitioners), source of payment, occupation, medical record number (if applicable), date of hospital admission (if applicable). |
| (b) | Living arrangements of the patient (for example, who lives with the patient, who administers medication). |
| (c) | Allergy history including a description of every food or drug reaction, the time of onset, the route of medicine administration, and the treatment. |
| (d) | Information regarding adverse drug reactions or predictable side effects from a drug or medicine product. |
| (e) | Descriptions of the family health history of certain diseases, conditions or risk factors for medicine therapy problems. |
| (f) | Special and unique needs such as physical limitations, special health care beliefs, language, compliance problems, diet and sleeping habits, and exercise. |
| (g) | Current medical problem list (both acute and chronic) including the patient's current complaints, symptoms, diagnoses, conditions, illnesses and how each of these problems is being treated. |
| (h) | Complete medicine history including: |
| (i) | All prescription medicines, non-prescription medicines, medication obtained from friends and family members, use of home remedies or traditional medicine, vitamins, natural and homeopathic remedies. |
| (ii) | The indication for every medication that the patient is taking, |
| (iii) | The person responsible for administering the medication. |
| (iv) | Health beliefs related to medicine use. During the initial interview, the pharmacist should determine the cultural issues that might influence the patient's compliance, attitudes towards the health care system and response to therapy. This profile could facilitate an effective pharmacist-patient relationship that ultimately results in positive outcomes. |
| (v) | Patient's level of understanding of the medication. |
| (vi) | The goals of the medicine therapy and any evidence of the patient's response to his or her particular medicine therapy. |
| (i) | Past medical history including any surgical procedures, hospitalisation and a list of all other medical problems that might have an impact on the patient's present and future care, medicine therapy problems, incidence of side-effects and history of poor response to specific agents or treatments. |
| (j) | Social history including tobacco, caffeine and alcohol use (including quantity used and length of use) and any history of illicit drug use. |
| (k) | Health maintenance information including information on cancer screening, immunisation history, history of sexually transmitted diseases, etc. |
| (l) | Information regarding the review of systems, for example vital signs (such as temperature, blood pressure and pulse rate), descriptions and experiences offered by the patient regarding the medical problems and laboratory information (for example, electrolyte concentrations, haemolytic profile, and liver and renal function tests). |
During the assessment phase the pharmacist should evaluate the patient's medicine therapy including any new prescription of a patient with the aid of all the information gathered in order to ascertain any of the following:
| (a) | the over-utilisation of medicine (i.e. the use of a medicine by a patient in quantities or for durations that are or can be regarded as not being in the interests of the patient); |
| (b) | the under-utilisation of medicine (i.e. the use of a medicine by a patient in an insufficient quantity to achieve a desired therapeutic goal); |
| (c) | therapeutic duplication of medicine (i.e. the use of two or more medicines from the same therapeutic class in such a way that the combined daily dose puts the patient at risk of an adverse medical result); |
| (d) | medicine/disease contra-indication (i.e. the potential for or the occurrence of an undesirable alteration of the therapeutic effect of a given medicine because of the presence of a disease condition in the patient or an adverse effect of the medicines on the patient's disease conditions); |
| (e) | adverse medicine interactions (i.e. the potential for or the occurrence of an adverse medical effect as a result of the patient using two or more medicines together); |
| (f) | incorrect medicine dosage(s); |
| (g) | incorrect duration of medicine treatment; |
| (h) | medicine/allergy interactions (i.e. the significant potential for or the occurrence of an allergic reaction as a result of medicine therapy); |
| (i) | clinical abuse or misuse of medicine; and |
| (j) | patient adherence/compliance. |
Where a new prescription must be dispensed this must be done in accordance with the standards laid down in section 2.7 of this manual.
| 2.25.3 | Development of a care plan (taking appropriate actions) |
The pharmacist must upon recognising any problem/situation as described above, take the appropriate steps which could include the development of a care plan to avoid or resolve the problem(s). Care plans are developed to define goals, determine appropriate interventions and to assess whether the patient's needs have been met. It also defines responsibilities of the patient and pharmacist for three different purposes:
| (a) | To resolve the medicine therapy problems identified during the assessment phase. |
| (b) | To meet the goals of the medicine therapy for each of the patient's medical conditions, thereby achieving the desired outcomes. |
| (c) | To prevent future medicine therapy problems from developing. |
The pharmacist must consult with the prescriber and/or the patient's medical practitioner when it is deemed necessary by the pharmacist to resolve a medicine-related problem. During this step it is also the responsibility of the pharmacist to provide adequate advice to the patient to ensure the safe and efficacious use of medicines. The patient should receive an unequivocal understanding of the instructions for use, and any distinct characteristics or requirements of the medicine. Counselling should cover matters that will enhance or optimise medicine therapy. Counselling of patients or their caregivers should thus include at least the following information—
| (a) | name and description of the medicine(s) used; |
| (b) | dosage form, dose, route of administration and duration of medicine therapy; |
| (c) | intended use of the medicine(s) and expected action; |
| (d) | special directions and precautions for preparation, administration and use by the patient; |
| (e) | common severe side or adverse effects or interactions and therapeutic contra-indications that may be encountered, including their avoidance, and the action required if they occur; |
| (f) | techniques for self-monitoring medicine therapy; |
| (g) | proper storage of medicine(s); |
| (h) | prescription repeat information; |
| (i) | action to be taken in the event of a dose not being taken; |
| (j) | any additional information which may be necessary. |
When the patient or the patient's caregiver is present, the pharmacist should consult with the patient/caregiver in person. Such a consultation should take place in an environment that allows for confidential conversation (refer section 1.2.13).
The care plan is completed when goals have been set, interventions agreed upon, and responsibilities of the patient and pharmacist are accepted. The pharmacist is then able to establish outcomes to be assessed during follow-up. The last step of the care-planning process is to schedule a time to conduct a follow-up evaluation.
| 2.25.4 | Follow-up evaluation |
The final step in the review process is the follow-up evaluation of the patient to determine actual patient outcomes. A follow-up evaluation is a patient encounter, either in person or by telephone, which allows the pharmacist to collect necessary information to determine whether the actions and interventions taken during the assessment and care planning have produced positive results. Since medicine therapy could produce both positive and negative results, a follow-up evaluation is vital. In addition, routine discussions with the patient's medical practitioner or other health care professionals might also be necessary.
These three steps provide the pharmacist with an organised logical mechanism to structure the provision and evaluation of care to patients. The above three steps occur continuously for a patient during treatment. The amount and type of work required at each step varies with the particular step and the specific needs of a patient. Other health care providers must be included in the patient care process when their input is needed to meet the patient's medicine-related needs. A pharmacist providing this service to patients is required to maintain the data base as per the standard and in addition to create and maintain reports reflecting each of the three steps of the pharmaceutical care service rendered.
