SHP REPORT

ASHP Guidelines on a Standardized Method

for Pharmaceutical Care

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Am J Health-Syst Pharm. 1996: 53:1713-6

Need for a standardized method pharmacotherapy series of the ASHP Clinical Skills
The purpose of this document is to provide phar­ Program.''''
macists with a standardized method for the provision of These Guidelines are not specific to any practice
pharmaceutical care in component settings of organ­ setting. ASHP believes this standardized method can be
ized health systems. Since the introduction of the phar­ used in acute care (hospitals), ambulatory care, home
maceutical care concept' and the development of the care, long-term care, and other practice settings. Func­
ASHP Statement on Pharmaceutical Care,- considerable tions can be tailored as appropriate for a given practice
variation in pharmacists' provision of pharmaceutical setting. It is recognized that the degree of standardiza­
care has been noted. ASHP believes pharmacists need a tion and tailoring appropriate for a given work site will
standardized method for providing pharmaceutical depend on the practice environment, the organization
care. of services (e.g., patient-focused or department-
This document describes a standardized method focused), working relationships with other health pro­
based on functions that all pharmacists should perform fessionals, the health system's and patient's financial
for individual patients in organized health systems. The arrangements, and the health system's policies and
use of this method would foster consistency in the procedures. ASHP believes the use of the systematic
provision of pharmaceutical care in all practice settings. approaches encouraged by these guidelines will assist
It would support continuity of care both within a pharmacists in implementing and providing pharma­
practice setting (e.g., among pharmacists on different ceutical care in their work sites.
work shifts caring for an acutely ill inpatient) and when
a patient moves among practice settings (e.g., when an Functions of phannaceutlcai care
inpatient is discharged to home or ambulatory care). ASHP believes that a standardized method for the
Further, a standardized method would establish consis­ provision of pharmaceutical care should include the
tent documentation so that patient-specific and medi­ following:
cation-related information could be shared from phar­ • Collecting and organizing paticnt-spccific informa­
macist to pharmacist and among health professionals. tion,
The need to identify the functions involved in phar­ • Determining the presence of medication-therapy
maceutical care and the critical skills necessary to pro­ problems,
• Summarizing patients' health care needs,
vide it was discussed at the San .Antonio consensus • Specifying pharmacotherapeutic goals,
conference in 1993.^ Functions for the provision of • Designing a pharmacotherapeutic regimen,
pharmaceutical care were identified by the practitioner • Designing a monitoring plan,
task force of the Scope of Pharmac\- Practice Project.^ • Developing a pharmacotherapeutic regimen and cor­
Those functions have been defined in more detail in the responding monitoring plan in collaboration with

Approved by the .ASHP Board of Directors, April 24, 1996. Devel­ Index terms: American Society of Health-System Pharma­
oped by the ASHP Council on Professional Affairs. cists; Guidelines; Organizations; Pharmaceutical care; Pharma­
The citation for this document is as follows: American Society cists; Pharmacy, institutional
of Health-System Pharmacists. ASHP guidelines on a standardized
method for pharmaceutical care. Am / Hcalth-S\st Phann. 1996; Copyright ® 1996, American Society of Health-System Phar­
53:1713-6. macists, Inc. All rights reserved. 1079-2082/96/0702-1713$06.(KI.

Vol 53 Jul 15 1996 Am J Hcalth-Syst Pharm 1713

ASHP Report Standardized method for pharmaceutical care

the patient and other health professionals, Social/Economic

• Initiating the pharmacotherapeutic regimen, Living arrangement
• Monitoring the effects of the pharmacotherapeutic Ethnic background
regimen, and Financial/insurance/health plan
• Redesigning the pharmacotherapeutic regimen and
monitoring plan. Objective and subjective information should be ob­
tained directly from patients (and family members,
These major functions have been adapted, in part, from
other caregivers, and other health professionals as
the pharmacotherapy series of the ASHP Clinical Skills
needed). A physical assessment should be performed as
Program and the final report of the ASHP Model for
needed. In addition, information can be obtained bv
Pharmacy Practice Residency Learning Demonstration
reviewing the patient's health record and other infor­
Project.
mation sources.
Collecting and organizing pertinent patient-
Information in the patient's health record should be
specific information. Information should be col­
understood, interpreted, and verified for accuracy be­
lected and used as a patient-specific database to pre­

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fore decisions are made about the patient's medication
vent, detect, and resolve the patient's medication-
therapy. With access to the patient's health record
related problems and to make appropriate medication-
comes the professional responsibility to safeguard the
therapy recommendations. The database should in­
patient's rights to privacy and confidentiality. The Pri­
clude the following sections, each containing specific
vacy Act of 1974,'" professional practice policies."
types of information to the extent that it is relevant to
and policies and procedures of organized health svs-
medication therapy:
tems provide guidance for the pharmacist in judging
Demographic the appropriate use of patient-specific information.
Name
The patient (as well as family members, caregivers,
Address
Date of birth and other members of the health care team as needed)
Sex should be interviewed. This is necessars" for the phar­
Religion and religious affiliation macist to establish a direct relationship with the pa­
Occupation tient, to understand the patient's needs and desired
Administrative outcome, to obtain medication-related information,
Physicians and prescribers and to clarify- and augment other available informa­
Pharmacy tion. Pharmacists in many practice settings, including
Room/bed numbers ambulatory- care, may need to perform physical assess­
Consent forms ments to collect data for assessing and monitoring
Patient identification number medication therapy.
Medical Information, including clinical laboratory test re­
Weight and height sults, gathered or developed by other members of the
Acute and chronic medical problems health care team may not be in the patient's health
Current symptoms record. Therefore, to ensure that the patient informa­
Vital signs and other monitoring information tion is current and complete, other sources should be
Allergies and intolerances
checked. Other sources may include medication pro­
Past medical history
Laboratoiy information files from other pharmacies used by the patient.
Diagnostic and surgical procedures Although it is ideal to have a comprehensive data­
base for all patients, time and staffing limitations mas-
Medication therapy
Prescribed medications necessitate choices regarding the quantity of informa­
Nonprescription medications tion and the number of patients to follow. Choices
Medications used prior to admission could be determined by the health system's policies and
Home remedies and other types of health products used procedures, by clinical care plans, or by disease manage­
Medication regimen ment criteria in the patient's third-party health plan.
Compliance with therapy Systems for recording patient-specific data will vary,
Medication allergies and intolerances depending on pharmacists' preferences and practice
Concerns or questions about therapy settings. Electronic documentation is recommended.
Assessment of understanding of therapy Some information may already be in the patient's
Pertinent health beliefs health record. Therefore, when authorized, the addi­
Behavioral/Lifestyle tional information gathered by the pharmacist should
Diet be recorded in the patient's health record so that it can
Exercise/recreation
be shared with other health professionals. Abstracted
Tobacco/alcohol/caffeine/other substance use or abuse
Sexual history summaries and work sheets may also be useful.
Personality type Determining the presence of medication-
Daily activities therapy problems. Conclusions should be drawn

1714 Am J Health-Syst Pha'rm Vol 53 Jul 15 1996

 Standardized method for pharmaceutical care ASHP Report

from the integration of medication-, disease-, laborato- management plans. The regimen should be designed
r\' test-, and patient-specific information. The patient's for optimal medication use within both the health
database should be assessed for any of the following system's and the patient's capabilities and financial
medication-therapy problems: resources.
• Medications with no medical indication, Designing a monitoring plan for the phar­
• Medical conditions for which there is no medication macotherapeutic regimen. The monitoring plan
prescribed,
should effectively evaluate achievement of the patient-
• Medications prescribed inappropriately for a particu­
lar medical condition, specific pharmacotherapeutic goals and detect real and
• Inappropriate medication dose, dosage form, sched­ potential adverse effects. Measurable, obsers'able pa­
ule, route of administration, or method of adminis­ rameters should be determined for each goal. End-
tration, points should be established for assessing whether the
• Therapeutic duplication, goal has been achieved. The needs of the patient,
• Prescribing of medications to which the patient is characteristics of the medication, needs of other health

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allergic,
• Actual and potential adverse drug events, care team members, and policies and procedures of the
• .Actual and potential clinically significant dmg-drug, health care setting will infiuence the monitoring plan.
drug-disease, dmg-nutrient, and drug-laboratory test Developing a pharmacotherapeutic regimen
interactions, and corresponding monitoring plan. Fhe regi­
• Interference with medical therapy by social or recre­ men and plan developed in collaboration with the
ational drug use, patient and other health professionals should be sys­
• Failure to receive the full benefit of prescribed med­ tematic and logical and should represent a consensus
ication therapy,
• Problems arising from the financial impact of medi­ among the patient, prescriber, and pharmacist. The
cation therapy on the patient, approach selected should be based on consideration of
• Lack of understanding of the medication therapy by the type of practice setting, its policies and procedures,
the patient, and practice standards, and good professional relations
• Failure of the patient to adhere to the medication with the prescriber and patient. The regimen and mon­
regimen. itoring plan should be documented in the patient's
The relative importance of problems must be as­ health record to ensure that all members of the health
sessed on the basis of specific characteristics of the care team have this information.
patient or the medication. Checklists, work sheets, and Initiating the pharmacotherapeutic regi­
other methods may be used to determine and docu­ men. Depending on the regimen and plan, the phar­
ment the presence of medication-therapy problems. macist could, as appropriate, implement all or portions
The method should be proactive and should be used of the pharmacotherapeutic regimen. .Actions should
consistently from patient to patient. comply with the health system's policies and proce­
Summarizing patients' health care needs. The dures (e.g., prescribing protocols) and correspond to
patient's overall needs and desired outcomes and other the regimen and plan. Orders for medications, labora­
health professionals' assessments, goals, and therapy tory tests, and other interventions should be clear and
plans should be considered in determining and docu­ concise. .All actions should be documented in the pa­
menting the medication-related elements of care that tient's health record.
are needed to improve or prevent deterioration of the Monitoring the effects of the pharmacother­
patient's health or well-being. apeutic regimen. Data collected according to the
Specifying pharmacotherapcutic goals. Phar- monitoring plan should be sufficient, reliable, and val­
macotherapeutic goals should reflect the integration of id so that judgments can be made about the effects of
medication-, disease-, laboratory test-, and patient- the pharmacotherapeutic regimen. Changes in patient
specific information, as well as ethical and quality-of-life status, condition, medication therapy, or nonmedica-
considerations. The goals should be realistic and consis­ tion therapy since the monitoring plan was developed
tent with goals specified by the patient and other mem­ should be considered. Missing or additional data
bers of the patient's health care team. The therapy should should be identified. .Achievement of the desired end-
be designed to achieve definite medication-related out­ points should be assessed for each parameter in the
comes and improve the patient's quality of life. monitoring plan, A judgment should be made about
Designing a pharmacotherapeutic regimen. whether the pharmacotherapeutic goals were met. Be­
The regimen should meet the pharmacotherapeutic fore the pharmacotherapeutic regimen is adjusted, the
goals established with the patient and reflect the inte­ cause for failure to achieve any of the pharmacothera­
gration of medication-, disease-, laboratory test-, and peutic goals should be determined.
patient-specific information; ethical and quality-of-life Redesigning the pharmacotherapeutic regi­
considerations; and pharmacoeconomic principles. It men and plan. Decisions to change the regimen and
should comply with the health system's medication- plan should be based on the patient's outcome. When
use policies, such as clinical care plans and disease clinical circumstances permit, one aspect of the regi-

Vol 53 Jul 15 1996 Am J Health-Syst Pharm 1715

 ASHP Report Standardized method for pharmaceutical care

men at a time should be changed and reassessed. Rec­ tional conference conducted by the American Society of Hos­
ommendations for pharmacotherapeutic changes pital Pharmacists and the ASHP Research Poundation. Am /
Hasp Plhirm. 1993; 50:1585-656.
should be documented in the same manner used to 4. Summaiy of the final report of the Scope of Pharmacy Prac­
document the original recommendations. tice Project. .4m ///osp P/zurm. 1994:51:2179-82.
5. Shepherd MF. Clinical skills program pharmacotherapy series
module 1. Reviewing patient medical charts. Bethesda. MD:
Pharmacist's responsibility American Society of Hospital Pharmacists: 1992.
An essential element of pharmaceutical care is that 6. Mason N, Shimp I.A. Clinical skills program pharmacothera­
the pharmacist accepts responsibility for the patient's py series module 2. Building a pharmacist's patient data base.
Bethesda, MD: American Societv of Hospital Pharmacists:
pharmacotherapeutic outcomes. The same commit­ 1993.
ment that is applied to designing the pharmacothera­ 7. Mason N, Shimp I.A. Clinical skills program pharmacothera­
peutic regimen and plan for the patient should be py series module 3. Constructing a patient's drug therapv
problem list. Bethesda, MD: American Society of Hospital
applied to its implementation. The provision of phar­
Pharmacists: 1993.
maceutical care requires monitoring the regimen's ef­

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8. Jones \VN, Campbell S. Clinical skills program pharmacother­
fects, revising the regimen as the patient's condition apy series module 4. Designing and recommending a phar­
changes, documenting the results, and assuming re­ macist's care plan. Bethesda, MD: American Society of Hospi­
tal Pharmacists: 1994.
sponsibility for the pharmacotherapeutic effects. 9. Frye CB. Clinical skills program pharmacotherapy series mod­
ule 5. Monitoring the pharmacist's care plan. Bethesda. MD:
American Societv of Hospital Pharmacists: 1994.
References
10. PL 93-579. 5 U.S.C.A. 552a (88 Stat. 1896).
1. Hepler CD, Strand LM. Opportunities and responsibilities in 11. ASHP guidelines for obtaining authorization for document­
pharmaceutical care. Am / Hasp I'luirm. 1990: 47:.S.'?,t-4.3. ing pharmaceutical care in patient medical records. Am I Ho\p
2. American Society of Hospital Pharmacists. ASHP statement P/rurm. 1989: 46:3.38-9.
on pharmaceutical care. Am I Hasp P/wrm. 1993; 50:1720-3. 12. Principles of practice for pharmaceutical care. Washington.
3. Implementing pharmaceutical care. Proceedings of an invita­ DC: American Pharmaceutical Association: 1995. '

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1716 Am J Health-Syst Pharm Vol 53 Jul 15 1996