"A Method of Documenting Pharmaceutical Care Utilizing Pharmaceutical"
A Method of Documenting Pharmaceutical Care Utilizing Pharmaceutical Diagnosis Stephen C. Hurley College of Pharmacy, Idaho State University, Campus Box 8333, Pocatello ID 83209-8333 This paper proposes an outline for writing-up a patient case that can be used by experienced pharmacy practitioners, or by students during case-study courses or clerkship training. When such written documen- tation is placed in the patient’s primary medical record it not only communicates pharmacotherapeutic evaluations and treatment recommendations but also serves as a record of pharmaceutical care. The well- known SOAP outline, even in an expanded format, is not satisfactory for pharmacy because it uses clinical information to characterize medical diagnoses rather than drug-related problems. The key element of the write-up is pharmaceutical diagnoses. Pharmaceutical diagnoses define the nature of specific drug-related problems. Each diagnosis serves as a foundation for desired outcomes, treatments, monitoring parameters, and subjects for patient counseling and education. INTRODUCTION therapy(1).” The issue was never resolved. In the case study In 1995, four semesters of case study courses were intro- course, students are required to learn three different ways to duced into the curriculum of the College of Pharmacy at write-up a patient case and clerkship faculty continue to use a Idaho State University. Faculty debated whether to use the variety of methods. The problem of students being ex- medical SOAP format or devise a new method of written posed to differing methods of written documentation is not documentation based on the “pharmacists workup of drug unique to Idaho State University. Prosser et al. developed a team-taught elective pharmacy course, for which a major American Journal of Pharmaceutical Education Vol. 62, Summer 1998 119 goal was to develop professional writing skills(2). They other with a new modular approach using pharmaceutical concluded that one reason students found it difficult to write diagnosis. Both versions contain about the same quantity of a “chart ready” note was that “each faculty member pre- clinical and therapeutic information. While the expanded sented a different perspective on the optimal format.” They SOAP case is also utilized to demonstrate several other also found that “writing skills, like clinical assessment skills, common writing problems it should be pointed out that are not easily acquired; it is a difficult and complex process.” these are not unique to the expanded SOAP format. They Subsequently, over the last two years, a considerable should be avoided within any format of written documenta- amount of time has been spent conducting a literature tion including the modular approach. search, studying published methods of documentation, con- The expanded SOAP version of the case begins with the ducting discussions with faculty, and field testing different chief complaint, history of present illness, past medical methods with both case study and clerkship students. The history, social history, medication history, physical exami- following outline is a culmination of this effort. Although nation and laboratory measurements. Much of this informa- not yet the standard for the College of Pharmacy, it has been tion is not necessary because it is already in the patient’s favorably received by both students and faculty. medical record. Wouldn’t it be better to have the student To write-up a patient case, effective organization and a prepare a write-up just the way a clinical pharmacist would well-developed flow of thought are very important. As in do it under actual practice conditions? Students need to any written composition, pharmacy documentation requires learn how to recognize and utilize essential patient data a proper introduction, relevant information, clear reasoning while filtering out the nonessential. The same reasoning and a conclusion. Many acronyms have been coined that applies to general discussions of disease states or pharmaco- suggest the proper steps to follow when writing-up a patient. therapeutics that are not applicable to the patient-specific For example, the SOIP, later changed to the well-known pharmaceutical diagnosis. These may be good learning as- SOAP (subjective, objective, analysis, plan), was originally signments, but they should be done separately and not designed by Dr. Lawrence L. Weed for medical doctors(3). included in the patient write-up. Other outlines include an expanded-SOAP (adds goals, After reviewing both versions of the case, consider the monitoring and education)(4,5), HOAP (replaces subjec- following questions. If you had limited time to read a tive and objective with history and observations)(6), pharmacist’s write-up, which format would be easier to SOAPIER (used by nursing: adds implementation, evalua- identify problems with the patient’s drug therapy, to know tion, revision)(7), DAR (used by nursing: data, action, exactly what changes in drug therapy were recommended, response)(7), FARM (findings, assessment, resolution, to efficiently monitor the patient the next day, to counsel the monitoring)(8,9), PWDT (pharmacist’s workup of drug patient, or to prepare a bill for cognitive services? therapy) (1), PMDRP (Pharmacist’s Management of Drug- Related Problems)(10), or the American Society of Health- NEW MODULAR FORMAT System Pharmacist’s PCP (pharmacist’s care plan)(11). The new format uses the following outline. In order to These various approaches all contain important ele- remember the steps in this outline one might use the ments of documentation, but they all suffer from one or following mnemonic “PH-MD-ROME.” more deficiencies. The original SOAP concentrates on de- velopment of a medical diagnosis rather than drug-related • Patient Introduction problems or pharmacotherapeutic assessment. The expanded • Health Problems SOAP and FARM emphasize therapeutic problems, but • Medications continue to be organized around medical diagnoses. The • Pharmaceutical Diagnoses PWDT is a lengthy “thought process that is meant to serve • Recommended Orders as a guideline for the documentation of clinical pharmacy • Desired Outcomes activities and not simply a form to be completed on each • Monitoring patient seen by a pharmacist(1).” It discusses, in a general • Patient Counseling and Education way, the issues that should be considered when evaluating a Patient Introduction patient data base and drug therapy, but does not describe The “Patient Introduction” module introduces the health what the final write-up should actually look like. The PMDRP professional to the patient. It provides a thumbnail sketch of is even more detailed than the PWDT. The authors state the patient’s appearance and the situations that motivated that “The PMDRP can be overwhelming for pharmacists the patient to seek care. It also lays the groundwork for what because of its detail and length.”(10) Length is also a prob- the pharmacist-patient relationship might involve. The fol- lem with the PCP. This method requires the pharmacist to lowing items would be included in this section; date of write- complete at least eight pages of forms. up, patient’s name, age (or date of birth), race, height, During the initial training of undergraduate pharmacy weight, admission date (applicable for inpatients), gender students, very detailed methods such as the PMDRP and the and Chief Complaint (CC) or a description of the patient’s PCP can help inexperienced students more fully internalize present state. The patient’s last name may be used in the aspects of the pharmaceutical care process. However, as remainder of the documentation. It is also common to refer students progress and develop a basic knowledge of thera- to “the patient,” or to use the patient’s initials. peutic principles, these methods become cumbersome and inefficient. Eventually the student will internalize most of Health Problems the concepts and will not need explicit prompting. Health problems may include a medical diagnosis, psy- In the Appendix, the same patient case is presented in chiatric diagnosis, patient complaint, an abnormal labora- two formats. These two formats will be used to illustrate tory test result, an abnormal observation (sign or symptom), differences in the way data can be presented and summa- a social or financial situation, a psychological concern, or a rized. One was organized with an expanded SOAP and the physical limitation/disability. Sometimes it is necessary for a 120 American Journal of Pharmaceutical Education Vol. 62, Summer 1998 pharmacist to perform a physical or psychological examina- the more important tools for developing and assessing pos- tion or question the patient about his or her medical history. sible drug-related problems(12). The pharmacist should not Documentation of these activities should be recorded within only determine the details of the past dosage regimens but this module. If the patient has an allergy, this should be also investigate how well those regimens worked, the details noted as the last item. If the patient has no known allergies, of any adverse events, and why the patient is no longer this should also be noted as confirmation that the pharma- taking the medications. The pharmacist should also assess cist has sought a history of allergies. patient knowledge, discover practical impediments to opti- Each health problem should be titled and placed in mal drug utilization, and determine if there are attitudinal order of clinical significance. Health problems should not be barriers that might have an impact on compliance(13). numbered because they are not the emphasis of the write- up, and it would lead to confusion when problems are Pharmaceutical Diagnoses numbered in the pharmaceutical diagnosis module. Early in the development of clinical pharmacy practice, At this location in the write-up, information on the medical diagnoses were used as the focus of thought pro- patient’s medical history is integrated with recent observa- cesses involved in establishing a systematic approach to tions in order to characterize the current health problem. drug therapy(14). The pharmaceutical care movement has Besides presenting clinical findings, there is often a need to stimulated pharmacy to reconsider and re-conceptualize the interpret or explain the data. For example, in both versions type of problems that fall within the scope of pharmacy of the case, the patient’s chronic bronchitis is attributed to practice. smoking and the acute exacerbation is hypothesized to be Strand et al. defined a drug-related problem as “an due to a viral infection and not a bacterial pneumonia. In the undesirable event, a patient experience that involves, or is modular format of the case, there is also an explanation that suspected to involve drug therapy, and that actually, or the increased serum bicarbonate is due to renal compensa- potentially, interferes with a desired patient outcome.”(15) tion, and that the patient’s mood and symptoms are compat- The authors further state that “some relationship must exist ible with diagnostic criteria for depression. (or be suspected to exist) between the undesirable event and Students often scatter relevant health information drug therapy. The nature of the relationship will depend throughout their write-ups. By putting the information sup- upon the specific drug-related problem, but common rela- porting a particular health problem in only one location, tionships between an undesirable event and drug therapy several pharmaceutical diagnoses can refer to the same are: (i) the event is the result of drug therapy; and (ii) the health/disease information without unnecessary duplica- event requires drug therapy.”(15) tion. For example, in the expanded SOAP format we find The original list of eight drug-related problems defined fragmented information about the patient’s chronic bron- by Strand et al. may be a good heuristic method to “provide chitis in the past medical history, social history, physical order in a pharmaceutical universe considered by many to examination, laboratory tests, and in the “S,” “O,” and “A” be chaotic,”(16) but it does not give many choices for titling of the SOAP under “Problem 1. Chronic Bronchitis Exacer- the numerous kinds of situations that could exist between bation.” While in the modular approach, all of this informa- drug therapy and an undesirable event. tion is organized under “Chronic Bronchitis in an Acute Pharmaceutical diagnosis is a concept discussed by Exacerbation.” Culbertson et al.(17). In the past, pharmacists have avoided Drug treatment is not discussed in the health problems the word “diagnosis” because diagnosis is supposed to be module. Past and present drug treatment will be listed in the only done by physicians. If medical diagnosis is defined by medications module and discussed, if necessary, in the phar- Stedman’s Medical Dictionary(18) as the “determination of maceutical diagnoses module. At this point, a health profes- the nature of a disease,” what would pharmacy diagnosis sional needs to develop an in-depth understanding of both be? the past course and present manifestations of the patient’s Culbertson et al. defined pharmaceutical diagnosis as “a medical/psychiatric problems without being distracted by a problem-centered, cognitive process used to identify pa- discussion of pharmacotherapeutics. tient-specific, drug-related problems,” and further proposed Identification of information as subjective, objective, a 23 pharmaceutical diagnostic categories organized under symptom or a sign has been overemphasized in the SOAP- seven general domains(17). They stated that the suggested type of note(6). The patient’s complaints and point of view diagnostic definitions were preliminary and “it is conceiv- are essential information, but they do not influence how the able that different definitions or an entirely new structure write-up is organized in the modular approach. Rather than may eventually emerge.” Table I contains an expanded list concentrating and organizing information by type (i.e., sub- of 42 possible pharmaceutical diagnosis with brief defini- jective versus objective) observations should be organized tions. These were developed from a review of the literature in a way that clarifies the relevant pathophysiology and (8,11,17,19) and tested by pharmacy students in numerous supports therapeutic discussions found in the pharmaceuti- simulated and actual patient cases. cal diagnoses module. In the narrative under each pharmaceutical diagnosis, the pharmacist should provide adequate evidence support- Medications ing the existence of a drug-related problem, and therapeutic The medication module is broken down into two sec- principles that will be used as a basis for solving the problem. tions; the present medication list and the past medication For example, the patient in the case exhibits a maculopapu- list. The present medication list can be used as a screen for lar rash. Both case formats conclude that the timing of the drug interactions, duplication of therapy, polypharmacy, rash is compatible with the initiation of doxycycline. Is this allergies, and appropriate dosage. enough evidence to convince a reader that the rash was due to In order to develop a past medication list a complete doxycycline rather than warfarin, terbutaline or acetami- drug history should be obtained. Drug histories are one of nophen? If the writer had done a comprehensive assessment American Journal of Pharmaceutical Education Vol. 62, Summer 1998 121 Table I. Suggested pharmaceutical diagnoses. Diagnosis Definition Related to Medical Diagnosis Incomplete medical evaluation Physician has not completed a diagnostic workup needed for evaluation of drug therapy. Uncharacterized signs and symptoms Physician has not yet initiated a diagnostic workup needed for evaluation of drug therapy. Related to the Prescription Unclear or incomplete prescription A prescription order is lacking essential information or needs clarification. Suboptimal dosage form There is a better dosage form or route i.e. parenteral, sustained release, liquids, tablets, capsules, flavor, topical, suppositories etc. Not receiving A drug has been recommended or prescribed but not dispensed, administered or refilled. Apply the poor compliance diagnosis when the patient is responsible for not taking the medication. Suboptimal dosage schedule Dosage schedule is either inconvenient or does not result in optimal pharmacokinetic or pharmacodynamic profile. Subtherapeutic dose Considering all patient-specific factors, the dosage is below that which normally will produce or sustain a satisfactory outcome. Excessive dose Considering all patient-specific factors, the prescribed dosage is higher than usually needed to produce satisfactory outcome and/or may place the patient at risk for an ADR Excessive duration of use Drug is no longer needed. Insufficient duration of use Drug was discontinued before desired outcome could be attained. Unidentified medication The patient does not know the name of a medication nor can it be easily identified by physical appearance. Related to Evaluation of Drug Therapy Untreated health problem An indication exists for drug or non-drug therapy. This diagnosis usually applies to a newly characterized health problem. However, it could apply to an older health problem if no other diagnosis is more descriptive of why the health problem is untreated. Need for prophylactic/preventative/ “Preventative” and “prophylactic” are often interchangeable, continuation continuation/or maintenance suppresses relapse while disease is in remission, maintenance reduces therapy recurrences after patient recovers. Suboptimal response Clinical evidence argues that the present drug treatment has been given an adequate trial in regard to dose and duration but does not meet desired outcomes related to efficacy. Questionable indication No apparent health problem for which the drug might be used. Uncertain indication Several health problems exist for which the drug might be used. Lacking justification An indication exists, but the literature strongly argues that the drug is either not very effective and/or has a high risk of adverse effects compared to other available alternatives. Questionable justification An indication exists, but the literature suggests that other alternatives are more effective and/or safer Duplication of action Two drugs are being given. One drug is sufficient, the other is probably not needed. Lacking pharmacokinetic evaluation Pharmacokinetic parameters need to be estimated and used to evaluate dosage and/ or drug levels. Related to Adverse Effects of Drug Therapy Adverse drug reaction An adverse drug reaction (ADR) is possibly, probably or definitely occurring. The undesirable event is caused by a drug,, unintended, noxious, and results in an adverse outcome. Absolute contra-indication The patient is at high risk for an ADR the etiology of which would involve a drug/ disease interaction Relative contra-indication The patient is at moderate risk for an ADR the etiology of which would involve a drug/disease interaction Potential adverse drug/diet interaction The patient is at risk for an ADR the etiology of which would involve diet. Potential adverse drug/drug interaction The patient is at risk for an ADR the etiology of which would involve an interaction between drugs. Potential drug/laboratory interaction The patient is at risk for an ADR, the adverse event would be an altered laboratory measurement. Related to Monitoring Need for prophylactic monitoring Patient is at risk for acquiring a health problem that would need drug therapy. Inadequate monitoring of clinical data Need for systematic observations of subjective and/or objective clinical data to either characterize a health problem, evaluate drug therapy or determine if desired outcomes are being met. Excessive monitoring of clinical data Some clinical measurements related to drug therapy are not necessary, resulting in increased cost, and/or inconvenience, and/or risk to the patient Inadequate therapeutic drug monitoring Systematic measurements of drug concentrations are needed for pharmacokinetic calculations or to assure that drug levels remain within the established therapeu- tic range. 122 American Journal of Pharmaceutical Education Vol. 62, Summer 1998 Table I. Suggested pharmaceutical diagnoses (con’t) Diagnosis Definition Excessive therapeutic drug monitoring Some drug concentration measurements are not necessary, resulting in increased cost, and/or inconvenience, and/or risk to the patient Unfinished trial of drug therapy More time needs to elapse before an evaluation of new, modified or discontinued drug therapy can be completed. Related to Patient Factors Poor compliance Usually refers to taking less than prescribed or not adhering to other directions for proper use. Problematic substance use Patient takes either a prescription drug or an illicit drug for the purpose of intoxica- tion. Detrimental physical dependence Dose reduction or drug discontinuation would lead to withdrawal symptoms. Intentional overdose Intentional self-administration of a potentially toxic dose. Excessive utilization Patient takes more than prescribed, or more than recommended for an OTC product, in an effort to increase therapeutic effect, but not for the purpose of intoxica tion. The resulting dose is excessive and may place the patient at risk for an ADR. Improper storage Refers to temperature, type of container, moisture, exposure to light, contamination, etc.. Related to Patient Counseling Deficient counseling There is a specific topic that needs to be included during patient counseling Poor technique using a device Patient Counseling needs to include a demonstration of proper technique and assurance that the patient will use the device properly in the future. Related to Costs Poor cost-effectiveness The present drug is more costly than another equally justified alternative. This diagnosis could refer to simply selecting another brand or generic product, or may refer to substitution with a different chemical entity. Financial burden Cost of a drug or the drug regimen may result in a serious financial barrier to the patient. of the potential adverse drug reaction it would have re- case documentation states that “the use of antibiotics in this quired evaluation of at least four pieces of evidence, only situation is controversial.” What does controversial mean? one of which is the temporal relationship between drug use Could the prescriber feel comfortable beginning ampicillin and an adverse event(20). Therefore the present case mate- when the risks and benefits are unknown. This would be a rial might be adequate for communication between health good location for the following abstract. professionals that trust each other’s judgment but might not be satisfactory when the intended reader has not developed A two-year, double blind, crossover study of 173 confidence in the pharmacist’s capabilities. patients with stable chronic obstructive pulmonary Establishment of a pharmaceutical diagnosis narrows disease compared antibiotics (TMP-SMX, or the options for therapy. However, there are always several amoxicillin, or doxycycline) with placebo during an ways to solve a problem. If a drug is to be initiated, modified, acute exacerbation. Although resolution of an ex- or discontinued, the benefits and risks should be discussed. acerbation within 21 days occurred in 68 percent of Therapeutic principles should be explained in enough detail the antibiotic treated patients, versus 55 percent of to educate or convince other health professionals that the the placebo treated patients (P<0.01), most of the rationale is appropriate. A limited discussion and compari- effect was accounted for by very symptomatic pa- son of alternate solutions may help clarify desirable options. tients(21). However, extensive information about alternate drug The methodology section within a current primary ar- therapy need only be included if there is a chance that a drug ticle can also demonstrate how experts monitor drug therapy of first choice may not meet expectations or has a potential and decide when a favorable outcome has been achieved. to produce significant adverse effects. This type of information is often difficult to extract from Referencing primary literature is an effective way to product information, textbooks and review articles. convince health professionals that your assessments or rec- ommendations are substantiated by current scientific evi- Recommended Orders dence. Primary references report the results of original This and the next three modules (outcomes, monitoring research, and support an analysis, an evaluation, or an and education) are designed to resolve drug-related prob- argument in areas that may be controversial, or where lems. Each suggestion within these modules should be pre- uncertainty exists. References should not refer to well- ceded by a number corresponding to a pharmaceutical known information that can be found in common medical or diagnosis. They are organized somewhat like check off lists. pharmacy textbooks or review articles. A primary journal Further data analysis, discussions or synthesis of plans would article can be summarized in two sentences. The first sen- only dilute the impact of proposed actions. Therefore, all tence describes the study duration, type of study, the num- narrative should be completed within the preceding health ber of final patients, type of patients, and the key indepen- problems module or pharmaceutical diagnoses module. dent variable. The second sentence provides the key depen- Recommendations usually deal with medications, but dent variable, result, and statistical significance. may involve non-drug therapies or another service. Non- An example is antibiotic use for chronic bronchitis. The drug therapy recommendations might include sending for American Journal of Pharmaceutical Education Vol. 62, Summer 1998 123 old medical records, contacting a health care provider or Chronic Bronchitis Exacerbation.” They are all mixed up in third party payer, providing drug information to a health one sentence. Now look at the modular write-up. As you can care provider, facilitating referral to health and social ser- see, they are basically the same parameters, but some are vice agencies, developing a compliance aid, etc. Recommen- done daily, and some only once, at a specific time. The dations concerning medications should be written as con- parameter to be done by the laboratory is clearly indicated. cisely as possible, using common prescription abbreviations, Terminology should be avoided that is general and may and list the specific drug, dosage form, dose, route, dosing not be uniformly interpreted by different readers. For ex- schedule and length of therapy. ample, in the expanded SOAP format under monitoring for In the expanded SOAP case, under the plan for chronic depression, how should we measure “quality of life?” There bronchitis exacerbation, a dose range was suggested for are published rating scales for quality of life. Are we going methylprednisolone. A specific dose, rather than a range is to use one of those, or are we just going to ask the patient more appropriate. It is also inappropriate to represent the about his quality of life? Under monitoring for side effects, dose using relative units based on weight such as “mg/kg.” A what is meant by “anticholinergic side effects?” Anticholin- pharmacist should have the expertise to determine the exact ergic side effects cover a broad range of symptoms. It would dose based on patient specific considerations such as seri- be better to select and specifically monitor a few of the more ousness of the health problem and pharmacokinetic calcula- common anticholinergic side effects. tions. In the ambulatory setting, a patient may not return to see the pharmacists for weeks or months. Between visits, the Desired Outcomes patient must be counseled to report if a health problem does Desired outcomes (also known as objectives or end- not resolve, or if side effects occur. Although this type of points) should be specific. They should state exactly what advice appears to be monitoring, it should be placed in the changes, or lack of changes, in the monitoring parameters next module “patient counseling and education.” would reasonably document the attainment of adequate therapeutic results, and assure that the patient was not Patient Counseling and Education experiencing any significant adverse drug reactions. Whereas This module lists specific, unique, and important infor- monitoring parameters are often repeated measurements, mation, advice, training, and encouragement that the phar- an outcome is a criterion that is applied to one or more of macist will provide to the patient. The purpose of counseling these measurements following a specific time interval. If the is to help the patient take appropriate responsibility for the outcome is not met it should be reevaluated and a new proper management of his or her illness and for recognizing outcome should be set. Outcomes are similar to mile mark- and dealing with side effects of medications. If there is a ers along a highway. They tell whether the patient has diagnosis of “poor compliance,” or a diagnosis related to progressed to a certain desirable point or not. patient counseling, then the patient counseling module must The synthesis of patient specific outcomes can only be contain directions for correcting the problems. accomplished after the pharmacist has a clear understand- A pharmacist does not have to prepare a written list of ing of the patient’s health problems and pharmaceutical all the subjects that are mandated in The Omnibus Budget diagnoses. In the context of a pharmacy write-up, analysis Reconciliation Act of 1990(22). However, the pharmacist should be completed in the health problems and pharma- will be responsible for discussing these items with the pa- ceutical diagnoses modules. If outcomes are presented too tient. For a general review of patient counseling, the reader early in the write-up they often turn out to be general health is referred to the ASHP Guidelines on Pharmacist-Con- or therapeutic goals and possibly unrealistic for specific ducted Patient Education and Counseling(23). patients. For example, in the expanded SOAP version of the The wording of this module should indicate if patient case, a goal to “decrease morbidity and mortality associated counseling has already been completed. If it has been com- with chronic bronchitis” is not patient specific. Even refin- pleted, the write-up should document the patient’s accep- ing the goal to “improve respiratory function and prevent a tance and apparent understanding of the information. If future exacerbation of chronic bronchitis,” or to “optimize patient counseling is performed at some later time the bronchodilator therapy” is not much better. In the modular pharmacist should return to the patient’s record and write a version of the case, the desired outcomes for pharmaceutical progress note confirming that the counseling was done, the diagnosis #1 “Suboptimal Response to Bronchodilators” date completed, and the pharmacist’s initials. explicitly state the values we want to achieve for: (i) FEV1; (ii) respiratory rate; and (iii) arterial blood gases. SUMMARY A pharmacist must know what to write before sitting down Monitoring and completing the document. This requires a thoughtful Monitoring parameters are those laboratory tests, clini- assessment of all available information in patient medical cal measurements, and observations that are to be prospec- records, a discussion with the physician and other caregivers, tively followed in order to provide feedback on the status of and an interview with the patient. As the pharmacy student the patient’s health problems and pharmaceutical diagnosis. or pharmacist becomes proficient, fewer notes and rough Each parameter should include the time when it will be drafts will be needed and the content and ideas will be easier obtained and by which health professional, if that is not to keep organized in his or her head. Although the modular implicitly clear. The most important monitoring parameters approach does not necessarily represent a thought-process are those that correspond to the outcomes above. Each for problem solving, the concepts embodied in the method monitoring parameter (or a few related parameters) should will hopefully result in a written product that more effec- be written on a separate line so that the result can be used as a tively communicates the results of such cognitive processes. check off list. In the expanded SOAP, notice how the Very little in a write-up can be simply copied down from the monitoring parameters were presented for “Problem 1. chart or other sources of patient information. The truly 124 American Journal of Pharmaceutical Education Vol. 62, Summer 1998 valuable information in a write-up is the ideas generated by Introduction, UpJohn Company, Kalamazoo MI (1992). the pharmacist. (16) Strand, L.M., Morley, P.C., Cipolle, R.J., Ramsey, R. and Lamsam, G.D., “Drug-related problems: their structure and function,” DICP In case study courses and clinical clerkships, a compre- Ann. Pharmacother., 24, 1093-1097(1990). hensive write-up may be many pages long. In the real world (17) Culbertson, V.L., Larson, R.A., Cady, P.S., Kale, M., Force, R.W., “A of pharmacy practice, a complete patient evaluation may be conceptual framework for defining pharmaceutical diagnosis,” Am. J. limited to one or two pages, and progress notes condensed Pharm. Educ., 61, 12-18(1997). to just a few paragraphs. Progress notes may not use all the (18) Dirckx, J.H., Stedman’s Concise Medical Dictionary for the Health Professions, 3rd ed., Williams and Wilkens, Baltimore MD (1997). modules; however, they should still include at least one (19) Rupp, M.T., Pharmacist Care Claim Form User’s Manual: A Guide to pharmaceutical diagnosis. In a progress note the pharmacist Pharmacist Care Compensation, NARD, Alexandria VA (1995) pp. may document changes in health problems, update pharma- 21-28. ceutical diagnoses, recommend new orders, document (20) Naranjo, C.A., Busto, U., Sellers, E.M., Sandor, P., Ruiz, I., Roberts, E.A., Janecek, E., Domecq, C. and Greenblatt, D.J., “A method for whether outcomes have been attained, report the results of estimating the probability of adverse drug reactions,” Clin. Pharmacol. monitoring, or record the success of patient counseling. Ther., 30, 239-245(1981). The modular write-up produces a document with an (21) Anthonisen, N.R., Manfreda, M.D., Warren, C.P.W., Hershfield, organized source of patient data, clear problem identifica- E.S., Harding, G.K.M., Nelson, N.A., “Antibiotic therapy in exacer- tion, and an explicit set of actions taken to resolve problems. bations of chronic obstructive pulmonary disease, “Ann. Intern. Med., 106, 196-204(1987). Summary reports based on a number of write-ups could be (22) OBRA ’90: A Practical Guide to Effecting Pharmaceutical Care, used to evaluate type of care provided, patient outcomes, American Pharmaceutical Association, Washingtion DC (1994). work load, costs and quality of care. Reimbursement or (23) “ASHP guidelines on pharmacist-conducted patient education and funding for non-dispensing, clinical service continues to be counseling,” Am. J. Health-Syst. Pharm., 54, 431-434(1997). an important goal for pharmacy. Just as the medical progress note and medical diagnosis are used for physician reim- bursement, pharmacy documentation and pharmaceutical APPENDIX: PATIENT CASE WRITTEN IN TWO diagnosis could serve the same function for pharmacists. DIFFERENT FORMATS Acknowledgment. The author would like to thank Dr. Joy 1. MODULAR FORMAT Matsuyama for submitting material used in the patient case. PATIENT INTRODUCTION Date 2/24/97 Am. J. Pharm. Educ., 62,119-127(1998); received 12/4/97, accepted 3/27/98. K.H. is a 52-year-old, 80 kg, 5’7” male who comes to the clinic today with continued complaints of shortness of breath and References increased sputum production. (1) Strand, L.M., Cipolle, R.J. and Morley, P.C., “Documenting the He reports that a rash began yesterday. clinical pharmacists activities: Back to basics,” Drug. Intell. Clin. He also complains of feeling depressed, lacking energy, wak- Pharm., 22, 63-67(1988). (2) Prosser, T.R. and Burke, J.M., “Teaching pharmacy students to write ing up early in the morning and not being able to go back to in the medical record,” Amer. J. Pharm. Educ., 61, 136-140(1997). sleep, a decreased appetite, and a general lack of interest in (3) Weed, L.L., Medical Records, Medical Education and Patient Care, everything, including his job and his family for the last 6 weeks. Case Western Reserve Press, Cleveland OH (1970). Although he has several medical problems, he has been doing (4) Wallace, C. and Franson, K.L., “Incorporation of ability-based out- well prior to this episode. come education into pharmacotherapeutics using an expanded S.O.A.P. format,” Am. J. Pharm. Educ., 60, 87-93(1996). HEALTH PROBLEMS (5) Schroeder, D.J., Gourley, D.R. and Herfindal, E.T., Casebook for Chronic Bronchitis in an Acute Exacerbation Herfindal & Gourley’s Textbook of Therapeutics Drug and Disease SOB has been increasing over the last two years. The present Management, 6th ed., Williams & Wilkins, Baltimore MD (1996) pp. XV-XXI. respiratory rate is increased to 32. K.H. continues to smoke 1 (6) Donnelly, W.J. and Brauner, D.J., “Why SOAP is bad for the medical pack per day. He has 50 pack-year history. Smoking is the most record,” Arch. Intern. Med., 152, 481-484(1992). likely etiology of the chronic bronchitis. Numerous rales, (7) Doenges, M.E., Moorhouse, M.F. and Burley, J.T., Application of rhonchi, and wheezes are heard on auscultation. Hct and Hgb Nursing Process and Nursing Diagnosis: An Interactive Text for are in the upper normal range ruling out anemia as a cause for Diagnostic Reasoning, F. A. Davis Company, Philadelphia PA (1995). the SOB. Their elevation is probably secondary to hypoxia. (8) Canaday, B.R. and Yarborough, P.C., “Documenting pharmaceutical Arterial blood gases indicate poor gas exchange, Pco2 is care: Creating a standard,” Ann. Pharmacother., 28,1292-1296(1994). increased to 49 mm/Hg (normal 35-45), and Po2 is decreased to (9) Ives, T.J., Canaday, B.R. and Yarborough, P.C., “Documentation of 55 mm/Hg (normal 80-100). An increased bicarbonate of 28 pharmacist interventions,” in Pharmacotherapy: A Patient-Focused mEq/L (normal 20-26) shows compensation by the kidney Approach, (edit. Schwinghammer, T.L.), Appleton & Lange, Stam- ford CT (1997) pp. 21-24. resulting in a pH of 7.37, which is low-normal. (10) Winslade, N.E., Bajcar, J.M., Bombassaro, A-M., Caravaggio, C.D., WBC and differential are normal, temperature is normal, Strong, D.K. and Yamashita, S.K., “Pharmacist’s management of and chest x-ray is clear ruling out pneumonia. Gram stain of drug-related problems: A tool for teaching and providing pharmaceu- sputum sample was unsuitable due to numerous squamous tical care,” Pharmacotherapy, 17, 801-809(1997). epithelial cells A viral upper respiratory tract infection may be (11) ASHP Clinical Skills Program: Pharmacotherapy Series, American the cause of the acute exacerbation. Society of Health-System Pharmacists, Bethesda MD (1994). A pre-bronchodilator FEV1 = 2000 mL (50% of VC) (12) Young, D.Y., “Research on the effects of pharmacist-patient commu- indicates obstruction. However a post-bronchodilator FEV1 nication in institutions and ambulatory care sites, 1969-1994,” Am. J. = 2600 mL (65% of VC) shows that this obstruction has a Health-Syst. Pharm., 53, 1277-1291(1996). reversible component. (13) Garner, M.E. and Herrier, R.N., “Case studies in patient communica- tion,” in Pharmacotherapy: A Patient-Focused Approach, (edit. Rash Schwinghammer, T.L.) Appleton & Lange, Stamford CT (1997) pp. K.H. does not complain of itching. He has a maculopapular 9-20. rash on trunk and thighs. His eosinophiles are in the normal (14) Kishi, D.T. and Watanabe, A.S., “A systematic approach to drug range. therapy for the pharmacist,” Amer. J. Hosp. Pharm., 31, 494-497( 1974). Depression (15) Strand, L.M., Cipolle, R.J. and Morley, P.C., Pharmaceutical Care: An The five symptoms mentioned under patient introduction and American Journal of Pharmaceutical Education Vol. 62, Summer 1998 125 their duration of over six weeks are consistent with a major 3 Patient’s appetite and sleep moderately improved within one depressive episode. However his breathing problem may be week and mood moderately improved within 4 weeks, with no contributing to the mood disorder. The patient does not report of suicidal ideation or side effects listed in monitoring appear to be suicidal at this point. below. Deep Vein Thrombosis Patient injured his right leg in a fall seven months ago. Deep MONITORING vein thrombosis in the calf developed a week later. The While hospitalized measurements of INR have shown wide swings over the last 1. Daily, patient’s report of SOB and sputum production seven months. Presently the INR has stabilized around 3.0 for Daily, respiratory rate and FEV1 the last two months. Daily, chest auscultation No Known Allergies In 4 days, laboratory to measure arterial blood gases 2. Daily, examine rash MEDICATIONS 3. Daily, dietary to record percent of each meal eaten, Present Medication List Daily, nursing to record hours of sleep the night before Theodur 600 mg bid for 2 years Daily, patient report of mood, interest in life, and suicidal Terbutaline inhaler 4 puffs qid and PM for 2 years thoughts Vibramycin 100 mg qd for bronchitis x 10 days 1.&3. Daily, patient report of adverse effects: headaches, anxiety, Warfarin 3 mg qd, started seven months ago insomnia, nausea, dry mouth, constipation, drowsiness, or Acetaminophen prn HA dizziness Past Medication List Unknown PATIENT COUNSELING AND EDUCATION 1. Assess K.H.’s ability to use his inhaler correctly and correct PHARMACEUTICAL DIAGNOSIS any problems. Provide a spacer if necessary. Explain the likely 1. Suboptimal Response to Bronchodilators side effects of bronchodilators: nausea, palpitations, anxiety K.H. has a symptomatic exacerbation of his chronic bronchitis or insomnia. K.H. should discontinue smoking; refer him to a that requires further treatment. The reversible airway ob- smoking cessation clinic. struction would probably be amenable to additional 2. Educate patient that he has an allergy to doxycycline and bronchodilators. A theophylline level of 12 mg/L is within the possibly other tetracyclines. therapeutic range and pharmacokinetically consistent with 3. Advise patient to take fluoxetine in the morning or at noon to his dosage. The use of antibiotics in this situation is controver- help prevent insomnia. Antacids may help with nausea. This sial, although recent evidence suggests a benefit. drug may cause drowsiness or dizziness, so caution is advised 2. Adverse Drug Reaction to Doxycycline when driving or operating machinery. It will take several K.H. has developed a rash probably due to the doxycycline weeks for this drug to work or side effects to develop. started 9 days ago. The usual drug rash is maculopapular and commonly occurs after 7-10 days of therapy. Avoid antihista- 2. EXPANDED SOAP FORMAT mines unless K.H. is itching, because they are sedating and have anticholinergic effects. CHIEF COMPLAINT 3. Untreated Depression K.H. is a 52-year-old man who comes to the clinic today with K.H. has had his current complaints for more than a month. complaints of shortness of breath and increased sputum pro- While he does not appear to be suicidal at this point, he needs duction. treatment. Fluoxetine is as effective, has less side effects, and, when all costs are taken into account, is no more expensive to HISTORY OF PRESENT ILLNESS use than older tricyclic antidepressants such as imipramine He reports that a rash began yesterday. and desipramine. He also complains of feeling depressed, lacking energy, wak- 4. Excessive Duration of Warfarin Prophylaxis ing up early in the morning and not being able to go back to Since the patient has only had one occurrence of deep vein sleep, a decreased appetite, and a general lack of interest in thrombosis, warfarin therapy is usually discontinued after six everything, including his job and his family for the last 6 weeks. months of prophylactic treatment Although he has several medical problems, he has been doing well prior to this episode. RECOMMENDED ORDERS 1. Methylprednisolone 45 mg iv stat and continue q 6 h for 72 PAST MEDICAL HISTORY hours. Chronic bronchitis secondary to smoking. Increasing SOB Aerosolized metaproterenol 4 puffs stat and 1 puff q 5 minutes over last two years. until relief or side effects, then two puffs every 4 hours while Patient injured his right leg in a fall seven months ago. Deep awake. vein thrombosis in the calf developed a week later. Continue oral theophylline, 600 mg bid. Oxygen 2 liters/minute via nasal prongs. SOCIAL HISTORY Ampicillin 500 mg po qid for seven days. K.H. has a stable and happy marriage; he has two sons in 2. Discontinue Vibramycin. college, both doing well. K.H. continues to smoke 1 pack per Label K.H. allergic to doxyclycline. day; he has 50 pack-year history. K.H. tried marijuana once Aveeno baths for a soothing effect as needed. with his son but did not like it. 3. Fluoxetine 20 mg qd in AM or at noon. Continue therapy for 6 months. MEDICATION HISTORY 4. Discontinue warfarin Theodur 600 mg bid for 2 years Terbutaline inhaler 4 puffs qid and PM for 2 years DESIRED OUTCOMES Vibramycin 100 mg qd for bronchitis x 10 days 1. FEV1 greater than 2000 mL within two days Warfarin 3 mg qd, started 7 months ago Respiratory rate below 20, within two days Acetaminophen prn headache ABG should all be within normal ranges within four days 2. Resolution of rash within 5 days 126 American Journal of Pharmaceutical Education Vol. 62, Summer 1998 ALLERGIES cultation, theophylline level, nausea, vomiting, pulse, blood None known glucose, serum potassium, blood pressure, and tremor. The goal is to decrease morbidity and mortality associated PHYSICAL EXAMINATION with chronic bronchitis. GEN: Middle aged man, in severe distress Assess K.H.’s ability to use his inhaler correctly and correct VS: BP 120/80, HR 100 reg, T 37.6, RR 32, Wt 80 kg, any problems. Provide a spacer if necessary. Explain the likely Ht 5’7” side effects of theophylline, steroids, and ampicillin. K.H. HEENT: Normal should discontinue smoking; refer him to a smoking cessation COR: Normal SI and S2; no S3, S4 or murmurs clinic. CHEST: Numerous rales, rhonchi, and wheezes ABD: No organomegaly PROBLEM 2. DRUG ALLERGY GU: WNL S: K.H. complains of a rash that began yesterday, but does not RECT: WN complain of itching. EXT: NL DTRs, maculopapular rash on trunk and O: K.H. has maculopapular rash on trunk and thighs, his Thighs eosinophiles are 1.2. NEURO: Oriented x 3, WNL A: K.H. has developed a rash due to the doxycycline started 9 days ago. The usual drug rash is maculopapular and com- RESULTS OF LABORATORY TESTS monly occurs after 7-10 days of therapy. Avoid antihistamines Na 140 Hct 55 Alb 4 K 4.0 unless K.H. is itching, because they are sedating and have Hgb 17.5 TBili .8 Cl 101 WBC 8.1 anticholinergic effects. Glu 95 Uric acid 7.4 HCO3 28 Pits 305k P: Discontinue Vibramycin. Aveeno baths for a soothing effect Ca 8.8 BUN 37 Cr 1.2 P04 2.6 may be needed. Label K.H. allergic to doxycycline. AST 40 ALT 35 Mg 2.0 PT 25(INR=3) Monitor for resolution of the rash. WBC differential: Neutrophils 4.8, bands 0, lymphs 3.0, monos Educate patient that he has an allergy to doxycycline and .5, eos .12 possibly other tetracyclines. ABGs: pH 7.37, Po2 55, PCO2 49 PFTs: pre-bronchodilator FEV1 = 2000 mL (50% of FVC), PROBLEM 3. DEPRESSION post-bronchodilator FEV1 = 2600 mL (65% of FVC) S: K.H. complains of feeling depressed, lacking energy, waking Gram stain of sputum sample was unsuitable due to numerous up early in the morning and not being able to go back to sleep, squamous epithelial cells a decreased appetite, and a general lack of interest in every- Urinalysis: WNL thing, including his job and his family for the last 6 weeks. Chest x-ray: Clear, no signs of pneumonia O: None. A: K.H. has had his current complaints for more than a month. PHARMACY-RELATED PROBLEM LIST While he does not appear to be suicidal at this point, he needs 1. Chronic bronchitis in an acute exacerbation treatment. Fluoxetine is as effective, has less side effects, and, 2. Drug allergy when all costs are taken into account, is no more expensive to 3. Depression use than older tricyclic antidepressants such as imipramine 4. Deep Vein Thrombosis and desipramine. P: Begin fluoxetine 20 mg qd in AM or at noon. Continue PROBLEM 1. CHRONIC BRONCHITIS EXACERBATION therapy for 6 months. S: K.H. complains of SOB and increased sputum production. Monitor changes in appetite, sleep pattern, interest in life, O: K.H. has a decreased FEV1, rales, rhonchi, wheezes, an mood, quality of life, and suicidal thoughts. Physiologic signs increased respiratory rate, pulse, Hct and Hgb, and arterial and symptoms should improve in 1 week, while mood will take blood gases that show an increased PCO2 and a decreased 2-4 weeks to respond. Also monitor for headaches, anxiety, oxygen. K.H. has a 50 pack-year smoking history. insomnia, nausea, somnolence, dizziness or anticholinergic A: K.H. has a symptomatic exacerbation of his chronic bronchitis side effects. that requires treatment. Smoking is the most likely etiology of Advise patient to take fluoxetine in the morning or at noon the chronic bronchitis, while a viral upper respiratory tract to help prevent insomnia. Antacids may help with nausea. infection is probably the cause of the acute exacerbation since This drug may cause drowsiness or dizziness, so caution is K.H. shows no signs of systemic bacterial infection. He has a advised when driving or operating machinery. It will take normal WBC, he is afebrile, and his chest x-ray is clear. The several weeks for this drug to work or side effects to develop. use of antibiotics in this situation is controversial, although recent evidence suggests a benefit. Pre-bronchodilator and PROBLEM 4. DEEP VEIN THROMBOSIS post-bronchodilator FEV1 show reversible airway obstruc- S: No complaints tion. The theophylline level is within the therapeutic range O: The measurements of INR have shown wide swings over the and there is no need to increase the dose. last seven months. Presently the INR has stabilized around 3.0 P: Give methylprednisolone 40-125 mg iv stat and continue q6h for the last two months. for 72 hours. Give aerosolized metaproterenol 4 puffs stat and A: Since the patient had only one occurrence of deep vein 1 puff q 5 minutes until relief or appearance of side effects. thrombosis, warfarin therapy is usually discontinued after six Continue oral theophylline. Begin oxygen 2 liters/minute via months of prophylactic treatment. nasal prongs. Begin ampicillin 500 mg po qid. P: Discontinue warfarin Monitor SOB, sputum production, FEV1, ABGs, chest aus American Journal of Pharmaceutical Education Vol. 62, Summer 1998 127