Schwinghammer instructor's gu.

Documentation of
Timothy J. Ives, PharmD, MPH, FCCP, BCPS Bruce R. Canaday, PharmD, BCPS, FASHP, FAPhAPeggy C. Yarborough, MS Pharm, CDE, FAPP, FASHP, NAPP If there is no documentation, then it didn’t happen! This philosophy is the standard in all health care settings as physicians, nurses, respiratory therapists, physical therapists, social workers, andother health care providers generate and maintain detailed notes regarding the patient’s situationand their efforts to achieve the best possible outcomes for the patient. Documentation chronologi-cally outlines the care the patient received and serves as a form of communication among healthcare providers, so that each practitioner involved knows what evaluation has occurred, what theplan for the patient’s treatment is, and who will provide it. Furthermore, third-party payers requirereasonable documentation from practitioners that assures that the services provided are consistentwith the insurance coverage.1 General principles for documentation include: • Documentation for each encounter with a rationale for the encounter, physical findings, prior test results, assessment, clinical impression (or diagnosis) and plan for care.
• The patient’s progress, response to and changes in treatment, and revision of the original di- Much of this documentation is derived from a systematic patient care process of evaluation that isstandardized within each discipline. For example, physicians are taught to perform a history and physical examination based upon a standardized review of body systems and to document theirresults using a universally accepted, standardized, systematic process.
Several evaluation/documentation systems have been suggested for health care professionals.
More than 30 years ago, the use of a Problem-Oriented Medical Record was proposed,2 and mostphysicians, nurse practitioners, physician associates, and other health care practitioners have beentaught to write progress notes using the Subjective, Objective, Assessment, Plan (SOAP) format.
Institutional consultant notes often use an abbreviated version of the SOAP format. This abbrevi-ated version usually includes Findings (i.e., subjective and objective information), Assessment (orImpression), and Diagnosis (or Recommendations). Other variations of this standard exist,3 such asSOAPER, which includes Education and Return instructions; SOAPIE, which includes Interven-tion and Evaluation; and SNOCAMP, which stands for Subjective, Nature of presenting problem,Objective, Counseling, Assessment, Medical decision making, and Plan. Because of the documen-tation guidelines proposed by the Centers for Medicare & Medicaid Services (formerly the HealthCare Financing Administration [HCFA]) for release in fiscal year 2001, older formats such asSOAP will no longer meet minimal criteria for appropriate documentation in most cases.
Historically, pharmacy has not had a corresponding standard approach to the evaluation and documentation of the patient’s pharmacotherapy that is applicable to all types of pharmacy practicesettings. Thus, pharmacy has not been as active as other disciplines in documenting its contribu-tions to patient care.
Pharmaceutical care uses a process through which a pharmacist cooperates with a patient and other health care professionals in designing, implementing, and monitoring a therapeutic plan thatwill produce specific therapeutic outcomes for the patient.4 This process involves three major func-tions: 1. Identifying potential and actual drug-related problems 2. Resolving actual drug-related problems 3. Preventing potential drug-related problems These functions aid in the provision of patient care through the identification of medication-relatedproblems, development of a pharmacotherapeutic plan to address the problems, and the ultimateresolution or prevention of those problems.
As described in Chapter 1, a systematic approach is used in this casebook to identify and resolve the medication-related problems of patients. The steps can be summarized as follows: 1. Identification of real or potential medication-related problems 2. -Determination of desired therapeutic outcomes and therapeutic endpoints 3. Determination of therapeutic alternatives 4. Design of an optimal pharmacotherapeutic plan for the patient 5. Identification of parameters to evaluate the outcome 100 ♦ Instructor’s Guide to accompany Pharmacotherapy Casebook, 5e 7. Communication and implementation of the pharmacotherapeutic plan Step 7 is crucial; the tenets of pharmaceutical care suggest that pharmacists should document, at the very least, the actual or potential medication-related problems identified, as well as the associ-ated interventions that they desire to implement or have implemented. The pharmacist must ade-quately communicate his or her recommendations and actions to non-pharmacy health care practi-tioners (e.g., physicians, nurses), the patient or caregiver (e.g., parents), or other pharmacists. Thegoal is to provide a clear, concise record of the actual/potential problem, the thought process that ledthe pharmacist to select an intervention, and the intervention itself. Additionally, the ability to re-ceive remuneration for services provided necessitates an acceptable documentation strategy.

In the SOAP note format, the subjective (S) and objective (O) data are recorded and then as- sessed (A) to formulate a plan (P). Subjective data include patient symptoms, things that may be ob-served about the patient, or information obtained about the patient. By its nature, subjective infor-mation is descriptive and generally cannot be confirmed by diagnostic tests or procedures. Much ofthe subjective information is obtained by speaking with the patient while obtaining the medical his-tory, as described in Chapter 1 (chief complaint, history of present illness, past medical history,family history, social history, medications, allergies, and review of systems). Important subjectiveinformation may also be obtained by direct interview with the patient after the initial medical his-tory has been performed (e.g., a description of an adverse drug effect, rating of pain severity usingstandard scales).
A primary source of objective information (O) is the physical examination. Other relevant ob- jective information includes laboratory values, serum drug concentrations (along with the targettherapeutic range for each level), and the results of other diagnostic tests (e.g., ECG, x-rays, cultureand sensitivity tests). Risk factors that may predispose the patient to a particular problem shouldalso be considered for inclusion. The communication note should include only the pertinent posi-tive and negative findings. Pertinent negative findings are signs and symptoms of the disease orproblem that are not present in the particular patient being evaluated.
The assessment (A) section outlines what the practitioner thinks the patient’s problem is, based upon the subjective and objective information acquired. This assessment often takes the form of adiagnosis or differential diagnosis. This portion of the SOAP note should include all of the reasonsfor the clinician’s assessment. This helps other health care providers reading the note to understandhow the clinician arrived at his or her particular assessment of the problem.
The plan (P) may include ordering additional diagnostic tests or initiating, revising, or discon- tinuing treatment. If the plan includes changes in pharmacotherapy, the rationale for the specificchanges recommended should be described. The drug, dose, dosage form, schedule, route of ad-ministration, and duration of therapy should be included. The plan should be directed towardachieving a specific, measurable, goal or endpoint, which should be clearly stated in the note. The Chapter 5 Documentation of Pharmacist Interventions ♦ 101 plan should also outline the efficacy and toxicity parameters that will be used to determine whetherthe desired therapeutic outcome is being achieved and to detect or prevent drug-related adverseevents. Ideally, information about the therapy that should be communicated to the patient shouldalso be included in the plan. The plan should be reviewed and referred to in the note as often as nec-essary.

There is a pharmacist equivalent of a physician’s progress note in a systematized approach for the construction and maintenance of a record reflecting the pharmacist’s contributions to care.5 Thisprocess includes provisions for the identification and assessment of actual or potential medica-tion-related problems, description of a therapeutic plan, and appropriate follow-up monitoring ofthe problems. Although there is no current uniform documentation system for the profession ofpharmacy, students are encouraged to try this system as they learn to document patient interven-tions and compare its effectiveness with the SOAP format. In this system, problems that have beenidentified are addressed systematically in a pharmacist’s note under the headings Findings, Assess-ment, Resolution, and Monitoring. The sections of the pharmacist’s note can be easily recalled withthe mnemonic FARM.
Identification of Drug-Related Problems
The first step in the construction of a FARM note is to clearly state the nature of the drug-related problem(s). Each problem in the FARM note should be addressed separately and assigned a sequen-tial number. Understanding the types of problems that may occur facilitates identification ofpharmacotherapy problems. Eight types of medication-related problems have been identified (seeChapter 1):6 Use of a classification system such as this for the various types of medication-related problems offers at least two advantages. First, it presents a framework, applicable in any practice setting, toassure that the pharmacist has considered each possible type of problem. Second, categorization al-lows optimal data analysis and retrieval capabilities. Thus, problems as well as the interventions toresolve them can be stored in a standardized format in a computer. When later analysis of this infor-mation is needed, such as determining how much money was saved through an intervention, how 102 ♦ Instructor’s Guide to accompany Pharmacotherapy Casebook, 5e outcomes were improved by the pharmacist, or how many problems of a certain type have occurred,the problems and interventions can be reviewed by groups rather than individually.
Documentation of Findings
Each statement of a drug-related problem should be followed by documentation of the pertinent findings (F) indicating that the problem may (potential) or does (actual) exist. Information includedin this section should include a summary of the pertinent information obtained after collection andthorough assessment of the available patient information. Demographic data that may be reportedinclude a patient identifier (name, initials, or medical record number), age, race (if pertinent), andgender. As noted earlier under the section on SOAP notes, medical information included in the noteshould include both subjective and objective findings that indicate a drug-related problem.
Assessment of Problems
The assessment (A) section of the FARM note includes the pharmacist’s evaluation of the cur- rent situation (i.e., the nature, extent, type, and clinical significance of the problem). This part of thenote should delineate the thought process that led to the conclusion that a problem did or did not ex-ist and that an active intervention either was or was not necessary. If additional information is re-quired to satisfactorily assess the problem and make recommendations, this data should be statedalong with its source (e.g., the patient, pharmacist, physician). The severity or urgency of the prob-lem should be indicated by stating whether the interventions that follow should be made immedi-ately or within one day, one week, one month, or longer. The desired therapeutic endpoint or out-come should be stated. This may include both short-term goals (e.g., lower blood pressure to<140/90 mm Hg in a patient with primary hypertension [therapeutic endpoint]) and long-term goals(e.g., prevent cardiovascular complications in that patient [therapeutic outcome]).
Problem Resolution
The resolution (R) section should reflect the actions proposed (or already performed) to resolve the drug-related problem based upon the preceding analysis. The note should convey that, after con-sideration of all appropriate therapeutic options, the option(s) considered to be the most beneficialwas either carried out or suggested to someone else (e.g., the physician, patient, or caregiver). Rec-ommendations may include nonpharmacologic therapy, such as dietary modification or assistingdevices (e.g., canes, walkers); the rationale for this method of treatment should be described. Ifpharmacotherapy is recommended, a specific drug, dose, route, schedule, and duration of therapyshould be specified. It is not sufficient to simply provide a list of choices for the prescriber. Impor-tantly, the rationale for selecting the particular regimen(s) should be stated. It is reasonable to in-clude alternative regimens that would be satisfactory if the patient is unable to complete treatmentwith the initial regimen because of adverse effects, allergy, cost, or other reasons. If patient counsel-ing is recommended, the information that will be included in the counseling session should be in-cluded. Conversely, if certain types of information will be withheld from the patient, the reasons fordoing so should be stated. If no action is recommended or was taken, that should be documented as Chapter 5 Documentation of Pharmacist Interventions ♦ 103 well. In this situation, the note serves as a record of the pharmacist’s involvement in the patient’scare. The pharmacist then has documentation that patient care activities were performed.
Monitoring for End Points and Outcomes
It is not enough, however, to only provide a clear, concise record of the nature of a problem, the assessment that led to the conclusion that a problem exists, and the selection of a plan for resolutionof the problem. In the spirit of pharmaceutical care, the patient must not be abandoned after an inter-vention has been made. A plan for follow-up monitoring (M) of the patient must be documented andadequately implemented. This process is likely to include questioning the patient, gathering labora-tory data, and performing the ongoing physical assessments necessary to determine the effect of theplan that was implemented to assure that it results in an optimal outcome for the patient.
Monitoring parameters to assess efficacy generally include improvement in or resolution of the signs, symptoms, and laboratory abnormalities that were initially assessed. The monitoring param-eters used to detect or prevent adverse reactions are determined by the most common and most seri-ous events known to be associated with the therapeutic intervention. Potential adverse reactionsshould be precisely described along with the method of monitoring. For example, rather than stat-ing “monitor for GI complaints,” the recommendation may be to “question the patient about thepresence of dyspepsia, diarrhea, or constipation.” The frequency, duration, and target endpoint foreach monitoring parameter should be identified. The points at which changes in the plan may bewarranted should be included. For example, in the case of a patient with dyslipidemia, one may rec-ommend to “obtain fasting HDL, LDL, total cholesterol, and triglycerides after 3 months of treat-ment. If the goal LDL of <100 mg/dL is not achieved with good compliance at 3 months, increasesimvastatin to 40 mg po QD. If goal LDL is achieved, maintain simvastatin 20 mg po QD and repeatfasting lipoprotein profile annually.” A SOAP or FARM progress note constructed in the manner described identifies each drug-re- lated problem and states the pharmacist’s Findings observed, an Assessment of the findings, the ac-tual or proposed Resolution of the problem based upon the analysis, and the parameters and timingof follow-up Monitoring. Either form of note should provide a clear, concise record of process, ac-tivity, and projected follow-up. When written for each medication-related problem, these notesshould provide data in a standardized, logical system. In particular, FARM notes provide a conve-nient format for progress notes for all pharmacists, applicable to any practice setting.
The following case presentation illustrates how such a system can be used in practice. Margaret Jones is a 62-year-old woman seen on rounds Monday morning. She was admitted the previous evening with complaints of shortness of breath, fever, and cough productive of greenishsputum. She has a history of type 2 diabetes, mild CHF, and is S/P MI. At home, she is maintained 104 ♦ Instructor’s Guide to accompany Pharmacotherapy Casebook, 5e on metformin 500 mg po BID, glyburide 10 mg po q AM, digoxin 0.125 mg po q AM, warfarin 5 mgpo q AM, aspirin 80 mg po q AM, furosemide 80 mg po BID, and metoprolol XL 100 mg po q AM.
The physical exam on admission revealed the following findings: VS
BP 168/88, P 88, RR 20 and labored, Tmax 103EF/39.4EC Cor
S3 gallop, PMI in the 6th intercostal space 3 cm distal to the midclavicular line Chest
Crackles and rales on the left; e-to-a changes and increased tactile fremitus over the leftlower and middle lung fields Ext
HEENT, GI, GU, Skin, Neuro
Labs on admission were unremarkable with the following exceptions:
WBC 16.0 × 103/mm3 with 12% bands and 0% eosinophils Sputum Gram stain
Chest x-ray
Left lower lobe consolidation with some diffuse patchiness in the left lower and middlelobes. Enlarged cardiac silhouette.
Probable community-acquired pneumonia (CAP) Meds on admission Sunday night
Acetaminophen 325 mg po q 6 h PRN temp >101EF/38.3ECGatifloxacin 500 mg po q AM for presumed CAP Azithromycin 500 mg po q AM for presumed CAP Chapter 5 Documentation of Pharmacist Interventions ♦ 105 Famotidine 20 mg po BID for ulcer prophylaxis Construction of a SOAP or FARM Note
Note: The Subjective and Objective findings of the SOAP note are combined into Findings for aFARM note. The Plan of the SOAP note is split into Recommendations/Resolution and Moni-toring/Follow-up in the FARM note. Subjective
Patient complains of SOB, fever, and cough with green sputum.
BP 168/88; P 88; T 103EF/39.4EC; R 20 and labored. Diminished breath sounds, e-to-a changes and increased tactile fremitus over the left lower and middle lung fields, 2+ pedal edema. SputumGram stain shows gram-positive cocci in pairs. WBC 16.0 × 103/mm3 with 12% bands, INR 3.5.
Blood glucose and HbA1c elevated. Chest x-ray indicates cardiomegaly and left lobe infiltrate.
Meds on Admission
Acetaminophen 325 mg PO q 6 h PRN temp >101EF/38.3ECGatifloxacin 500 mg po q AM + azithromycin 500 mg po q AM for presumed community-ac- Metformin 500 mg po BID + glyburide 10 mg po q AM for type 2 diabetes Digoxin 0.125 mg po q AM + furosemide 80 mg po BID for CHF Warfarin 5 mg po q AM + aspirin 80 mg po QD + metoprolol XL 100 mg po q AM S/P MI Famotidine 20 mg po BID for ulcer prophylaxis Assessment
1. Community-acquired pneumonia: probably pneumococcal in origin. Azithromycin appears to be unnecessary without indication for atypical pneumonia.
2. Hypertension: currently untreated. BP of 168/88 would usually be classified as isolated sys- tolic HTN, but present measurements may reflect infection and fever. The heart rate of 88while on metoprolol and digoxin is a relative tachycardia, assuming that in the baseline en-vironment the drugs would achieve a HR of 60 to 80 bpm.
3. CHF: Pedal edema and cardiomegaly on chest x-ray. Receiving no ACE inhibitor.
106 ♦ Instructor’s Guide to accompany Pharmacotherapy Casebook, 5e 4. Anticoagulation: INR above target range of 2.0 to 3.0. Identify and remove causes or reduce 5. Type 2 diabetes mellitus: HbA1c above goal of <7%. Not receiving ACE inhibitor for renal 6. Lipid panel: no recent results available; goal LDL is <100 mg/dL in patient with existing 7. Adverse effects: although metoprolol is a $1-selective b-blocker, consider that its $2-block- ing properties (usually at higher doses) may contribute to SOB due to bronchoconstriction,negative inotropic effects, or both.
8. Medication without indication: There appears to be no need for famotidine in this situation.
1. Continue acetaminophen 325 mg po q 6 h PRN temp 101EF/38.3EC 2. Change gatifloxacin to 400 mg po QD, the dose indicated for community-acquired pneumo- nia (does not come in 500-mg strength); discontinue azithromycin.
3. D/C metformin during hospital stay, in light of potential hypoxia/hypoperfusion during 4. Change glyburide 10 mg to glipizide XL 10 mg po QD.
5. Continue digoxin 0.125 mg po q AM.
6. Give warfarin 2.5 today and then resume 5 mg po QD; dose to be adjusted as needed based 8. Increase furosemide to 100 mg po BID because of persistent pedal edema.
9. Hold metoprolol until cause of SOB is identified.
10. D/C famotidine because of lack of indication in this patient.
11. Start enalapril 10 mg po QD to reduce mortality from CHF, provide protection from di- abetic-associated nephropathy, and help control HTN.
12. Obtain fasting lipid panel and start medical nutrition therapy and pravastatin 10 mg po 13. Provide nasal O2 if appropriate for SOB.
Chapter 5 Documentation of Pharmacist Interventions ♦ 107 14. Obtain admission weight, and then measure daily weight. Obtain prior outpatient weight to serve as baseline if available.
15. Diet: 3 meals with bedtime snack, with no concentrated carbohydrate (CHO) choices.
Limit CHO intake per meal to 60 g; snacks 15–20 g CHO. No added salt.
18. Supplement glyburide with insulin lispro for excessive premeal BG, based on an esti- mated insulin sensitivity of 1 unit per 30 to 40 mg/dL: 6 units, and test for urinary ketones.
Call MD if ketones moderate or large.
19. Anticipate reinstitution of metformin upon resolution of respiratory distress, peripheral edema, clearing of lung fields, and verification of SCr <1.4 mg/dL.
1. Obtain admission digoxin level and repeat q 5 days while taking gatifloxacin.
2. Check baseline electrolytes (K, Na, Ca, Mg levels in light of unopposed furosemide therapy of unknown duration, with digoxin), serum creatinine, and fasting lipid panel.
5. Monitor Q shift: vital signs, peripheral edema, lung sounds, labored breathing, sputum pro- duction (quality & quantify), dehydration, O2 saturation.
1. Documentation Guidelines for Evaluation and Management Services. Washington, DC, Health Care Financing Administration, December 2000.
2. Weed LL. Medical records that guide and teach. N Engl J Med 1968;278:593–600, 652–657.
3. Larimore WL, Jordan EV. SOAP to SNOCAMP: Improving the medical record format. J Fam 108 ♦ Instructor’s Guide to accompany Pharmacotherapy Casebook, 5e 4. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp 5. Canaday BR, Yarborough PC. Documenting pharmaceutical care: Creating a standard. Ann 6. Strand LM, Morley PC, Cipolle RJ, et al. Drug-related problems: Their structure and function.
Ann Pharmacother 1990;24:1093–1097.
Chapter 5 Documentation of Pharmacist Interventions ♦ 109


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