Principles of Practice for Pharmaceutical Care

Preface/Introduction:
Pharmaceutical Care is a patient-centered, outcomes oriented pharmacy practice that requires the
pharmacist to work in concert with the patient and the patient's other healthcare providers to
promote health, to prevent disease, and to assess, monitor, initiate, and modify medication use to
assure that drug therapy regimens are safe and effective. The goal of Pharmaceutical Care is to
optimize the patient's health-related quality of life, and achieve positive clinical outcomes, within
realistic economic expenditures. To achieve this goal, the following must be accomplished:

1. A professional relationship must be established and maintained.

Interaction between the pharmacist and the patient must occur to assure that a relationship based
upon caring, trust, open communication, cooperation, and mutual decision making is established
and maintained. In this relationship, the pharmacist holds the patient's welfare paramount,
maintains an appropriate attitude of caring for the patient's welfare, and uses all his/her
professional knowledge and skills on the patient's behalf. In exchange, the patient agrees to
supply personal information and preferences, and participate in the therapeutic plan. The
pharmacist develops mechanisms to assure the patient has access to pharmaceutical care at all
times.

2. Patient-specific medical information must be collected, organized, recorded, and

maintained.

Pharmacists must collect and/or generate subjective and objective information regarding the
patient's general health and activity status, past medical history, medication history, social
history, diet and exercise history, history of present illness, and economic situation (financial and
insured status). Sources of information may include, but are not limited to, the patient, medical
charts and reports, pharmacist-conducted health/physical assessment, the patient's family or
caregiver, insurer, and other healthcare providers including physicians, nurses, mid-level
practitioners and other pharmacists. Since this information will form the basis for decisions
regarding the development and subsequent modification of the drug therapy plan, it must be
timely, accurate, and complete, and it must be organized and recorded to assure that it is readily
retrievable and updated as necessary and appropriate. Patient information must be maintained in
a confidential manner.

3. Patient-specific medical information must be evaluated and a drug therapy plan

developed mutually with the patient.

Based upon a thorough understanding of the patient and his/her condition or disease and its
treatment, the pharmacist must, with the patient and with the patient's other healthcare providers
as necessary, develop an outcomes-oriented drug therapy plan. The plan may have various
components which address each of the patient's diseases or conditions. In designing the plan, the
pharmacist must carefully consider the psycho-social aspects of the disease as well as the
potential relationship between the cost and/or complexity of therapy and patient adherence. As
one of the patient's advocates, the pharmacist assures the coordination of drug therapy with the
patient's other healthcare providers and the patient. In addition, the patient must be apprised of
(1) various pros and cons (i.e., cost, side effects, different monitoring aspects, etc.) of the options
relative to drug therapy and (2) instances where one option may be more beneficial based on the
pharmacist's professional judgment. The essential elements of the plan, including the patient's
responsibilities, must be carefully and completely explained to the patient. Information should be
provided to the patient at a level the patient will understand. The drug therapy plan must be
documented in the patient's pharmacy record and communicated to the patient's other healthcare
providers as necessary.

4. The pharmacist assures that the patient has all supplies, information and knowledge
necessary to carry out the drug therapy plan.

The pharmacist providing Pharmaceutical Care must assume ultimate responsibility for assuring
that his/her patient has been able to obtain, and is appropriately using, any drugs and related
products or equipment called for in the drug therapy plan. The pharmacist must also assure that
the patient has a thorough understanding of the disease and the therapy/medications prescribed in
the plan.

5. The pharmacist reviews, monitors, and modifies the therapeutic plan as necessary and
appropriate, in concert with the patient and healthcare team.

The pharmacist is responsible for monitoring the patient's progress in achieving the specific
outcomes according to strategy developed in the drug therapy plan. The pharmacist coordinates
changes in the plan with the patient and the patient's other healthcare providers as necessary and
appropriate in order to maintain or enhance the safety and/or effectiveness of drug therapy and to
help minimize overall healthcare costs. Patient progress is accurately documented in the
pharmacy record and communicated to the patient and to the patient's other healthcare providers
as appropriate. The pharmacist shares information with other healthcare providers as the setting
for care changes thus helping assure continuity of care as the patient moves between the
community setting, the institutional setting, and the long-term care setting.

Practice Principles
A. Data Collection

1. The pharmacist conducts an initial interview with the patient for the purposes of establishing a
professional working relationship and initiating the patient's pharmacy record. In some situations
(e.g. pediatrics, geriatrics, critical care, language barriers) the opportunity to develop a
professional relationship with and collect information directly from the patient may not exist.
Under these circumstances, the pharmacist should work directly with the patient's parent,
guardian, and/or principal caregiver.

2. The interview is organized, professional, and meets the patient's need for confidentiality and
privacy. Adequate time is devoted to assure that questions and answers can be fully developed
without either party feeling uncomfortable or hurried. The interview is used to systematically
collect patient-specific subjective information and to initiate a pharmacy record which includes
information and data regarding the patient's general health and activity status, past medical
history, medication history, social history (including economic situation), family history, and
history of present illness. The record should also include information regarding the patient's
thoughts or feelings and perceptions of his/her condition or disease.

3. The pharmacist uses health/physical assessment techniques (blood-pressure monitoring, etc.)

appropriately and as necessary to acquire necessary patient-specific objective information.

4. The pharmacist uses appropriate secondary sources to supplement the information obtained
through the initial patient interview and health/physical assessment. Sources may include, but are
not limited to, the patient's medical record or medical reports, the patient's family, and the
patient's other healthcare providers.

5. The pharmacist creates a pharmacy record for the patient and accurately records the
information collected. The pharmacist assures that the patient's record is appropriately organized,
kept current, and accurately reflects all pharmacist-patient encounters. The confidentiality of the
information in the record is carefully guarded and appropriate systems are in place to assure
security. Patient-identifiable information contained in the record is provided to others only upon
the authorization of the patient or as required by law.

B. Information Evaluation

1. The pharmacist evaluates the subjective and objective information collected from the patient and other
sources then forms conclusions regarding: (1) opportunities to improve and/or assure the safety,
effectiveness, and/or economy of current or planned drug therapy; (2) opportunities to minimize current
or potential future drug or health-related problems; and (3) the timing of any necessary future pharmacist
consultation.

2. The pharmacist records the conclusions of the evaluation in the medical and/or pharmacy record.

3. The pharmacist discusses the conclusions with the patient, as necessary and appropriate, and assures an
appropriate understanding of the nature of the condition or illness and what might be expected with
respect to its management.

C. Formulating a Plan

1. The pharmacist, in concert with other healthcare providers, identifies, evaluates and then
chooses the most appropriate action(s) to: (1) improve and/or assure the safety, effectiveness,
and/or cost-effectiveness of current or planned drug therapy; and/or, (2) minimize current or
potential future health-related problems.
2. The pharmacist formulates plans to effect the desired outcome. The plans may include, but are
not limited to, work with the patient as well as with other health providers to develop a patient-
specific drug therapy protocol or to modify prescribed drug therapy, develop and/or implement
drug therapy monitoring mechanisms, recommend nutritional or dietary modifications, add non-
prescription medications or non-drug treatments, refer the patient to an appropriate source of
care, or institute an existing drug therapy protocol.

3. For each problem identified, the pharmacist actively considers the patient's needs and
determines the desirable and mutually agreed upon outcome and incorporates these into the plan.
The plan may include specific disease state and drug therapy endpoints and monitoring
endpoints.

4. The pharmacist reviews the plan and desirable outcomes with the patient and with the patient's
other healthcare provider(s) as appropriate.

5. The pharmacist documents the plan and desirable outcomes in the patient's medical and/or
pharmacy record.

D. Implementing the Plan

1. The pharmacist and the patient take the steps necessary to implement the plan. These steps
may include, but are not limited to, contacting other health providers to clarify or modify
prescriptions, initiating drug therapy, educating the patient and/or caregiver(s), coordinating the
acquisition of medications and/or related supplies, which might include helping the patient
overcome financial barriers or lifestyle barriers that might otherwise interfere with the therapy
plan, or coordinating appointments with other healthcare providers to whom the patient is being
referred.

2. The pharmacist works with the patient to maximize patient understanding and involvement in
the therapy plan, assures that arrangements for drug therapy monitoring (e.g. laboratory
evaluation, blood pressure monitoring, home blood glucose testing, etc.) are made and
understood by the patient, and that the patient receives and knows how to properly use all
necessary medications and related equipment. Explanations are tailored to the patient's level of
comprehension and teaching and adherence aids are employed as indicated.

3. The pharmacist assures that appropriate mechanisms are in place to ensure that the proper
medications, equipment, and supplies are received by the patient in a timely fashion.

4. The pharmacist documents in the medical and/or pharmacy record the steps taken to
implement the plan including the appropriate baseline monitoring parameters, and any barriers
which will need to be overcome.

5. The pharmacist communicates the elements of the plan to the patient and/or the patient's other
healthcare provider(s). The pharmacist shares information with other healthcare providers as the
setting for care changes, in order to help maintain continuity of care as the patient moves
between the ambulatory, inpatient or long-term care environment.
E. Monitoring and Modifying the Plan/Assuring Positive Outcomes

1. The pharmacist regularly reviews subjective and objective monitoring parameters in order to
determine if satisfactory progress is being made toward achieving desired outcomes as outlined
in the drug therapy plan.

2. The pharmacist and patient determine if the original plan should continue to be followed or if
modifications are needed. If changes are necessary, the pharmacist works with the
patient/caregiver and his/her other healthcare providers to modify and implement the revised
plan as described in "Formulating the Plan" and "Implementing the Plans" above.

3. The pharmacist reviews ongoing progress in achieving desired outcomes with the patient and
provides a report to the patient's other healthcare providers as appropriate. As progress towards
outcomes is achieved, the pharmacist should provide positive reinforcement.

4. A mechanism is established for follow-up with patients. The pharmacist uses appropriate
professional judgement in determining the need to notify the patient's other healthcare providers
of the patient's level of adherence with the plan.

5. The pharmacist updates the patient's medical and/or pharmacy record with information
concerning patient progress, noting the subjective and objective information which has been
considered, his/her assessment of the patient's current progress, the patient's assessment of
his/her current progress, and any modifications that are being made to the plan. Communications
with other healthcare providers should also be noted.