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Clinical Pharmacy Manual

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Clinical Pharmacy Manual
Hospital Sector
Pharmacy Department
Clinical Pharmacy Section

2021
Clinical Pharmacy Manual

Clinical Pharmacy Section

The practice of clinical pharmacy embraces the philosophy of pharmaceutical
care; it blends a caring orientation with specialized therapeutic knowledge,
experience, and judgment for the purpose of ensuring optimal patient outcomes.
It is regarded as an imperative part of a health care team to provide the best
quality use of medicines.

This goal can be achieved by participation in the management of individual

patients, incorporation of the best available evidence, and transfer of this
knowledge to health care professionals in all practice settings to guarantee the
utmost possible quality of patient care. It improves the level of patients’ care
by increasing the quality of therapy with the least expensive for a health care
system. That is achieved by the presence of clinical pharmacists in medical
rounds who could assist physicians in optimizing patients’ pharmacotherapy.
Moreover, clinical pharmacists may reduce adverse effects and medication
errors insofar as they contribute significantly to the detection and management
of drug-related problems, thus preventing extended hospitalization and reducing
the associated cost of treatment.

Our ultimate aim and focus, through the allocation of our resources are optimizing
therapy and promoting health, wellness, and disease prevention for promoting
patient health. That is achieved by caring values with specialized knowledge,
experience, and judgment underscores the critical importance of the synergy
achieved by combining a caring ethos, in-depth therapeutic knowledge, clinical
experience, and expert judgment. As a discipline, the clinical pharmacy must
be engaged also in continuous research to contribute to the generation of new
knowledge that advances human health and quality of life.

Within the constantly evolving system of healthcare, the role of clinical

pharmacists is becoming more important. Being experts in the therapeutic
use of medications clinical pharmacists routinely provide medication therapy
evaluations and recommendations to patients and health care professionals
are a primary source of scientifically valid information and advice regarding the
safe, appropriate, and cost-effective use of medications.

Dr. Yousif Mohamed Alserkal

Director General Emirates Health Services Establishment

Today’s healthcare system demands pharmacists to provide patient care that
optimizes medication therapy and promotes health, wellness, and disease
prevention through continuous research finding the state of art treatment
protocols and the only health science discipline that allows for this is Clinical
Pharmacy. This necessitates the presence of a clinical pharmacist amongst the
healthcare team to care for patients in all health care settings. Accordingly, clinical
pharmacists assume responsibility and accountability for managing medication
therapy in direct patient care settings, whether practicing independently or
in consultation/collaboration with other health care professionals. Clinical
pharmacist researchers generate, disseminate, and apply new knowledge that
contributes to improved health and quality of life.

Due to the pivotal role of clinical pharmacy in the health care system, and the
sound judgment of the pharmacist among the healthcare team the Ministry of
Health and Protection in the United Arab Emirates has shed the light on this
health science discipline. By integrating clinical pharmacy and rendering it an
integral part of the health care system, by supporting its activities, standardizing
the clinical practice, promoting the evidence-based medicine approach,
focusing on medication use and continuously monitoring its progression that is
justified with the act of publishing this manual.

Afterall It is easy to get a thousand prescriptions, but hard to get one single
remedy.

Dr. Amal Saeed Al Awadhi

Director of the Pharmacy Department

The MoHP would like to acknowledge and thank the following members of the
Clinical Pharmacy Team for their dedication in developing this manual aiming
to improve the quality and safety of healthcare services.

• Dr. Amin Mohamed Elshamy (Team Lead)

• Dr. Mouza Sulaiman Al Saadi
• Dr. Amal Mohamed Alsereidi
• Dr. Sabaa Alhemyari
• Dr. Basma Hatim Al Baloushi
• Dr. Halima Salem Al Dhanhani
• Dr. Alia Mahmood Aljasmi
• Dr. Ayman Ahmad Chkhis
• Dr. Duaa Salem Jawhar

Scope of the Manual

In general, the document shall be implemented in health facilities of UAE to
improve clinical pharmacy practice or service. However, it also touches cross-
cutting issues related to CPS such as clinical pharmacy education and research.
Even though, this document may not address all the existing problems related
to CP practice, education, and research, it can serve as a guidance on the
areas of collaboration with key stakeholders to improve the overall CPS. To
improve treatment outcome, quality of care and patient safety, private health
facilities and community pharmacies are recommended to provide CPS in the
necessary areas of patient care by adapting the principles, core activities and
processes described in this guideline.

Copyright © 2021 by MOHAP

All rights reserved. No part of this manual maybe reproduced or used
in any manner without written permission of the copyright owner
except for the use of brief quotations in a book review.
Contents

Abbreviations �����������������������������������������������������������������������2

1. Introduction����������������������������������������������������������������������1

2. Clinical pharmacy service components�����������������������������������2

3. Patient care process�������������������������������������������������������� 21

4. Component of patient’s medical record�������������������������������� 26

5. Clinical pharmacist’s competency standards in patient care������ 29

6. Clinical Pharmacy Competencies���������������������������������������� 31

7. References�������������������������������������������������������������������� 39

8. Appendix: Job Description Forms���������������������������������������� 40

Abbreviations

• ACCP American College of Clinical Pharmacy

• BP Blood Pressure
• CC Chief Complaint
• CT Computed Tomography
• DRP Drug-Related Problem
• FH Family History
• GP General Practitioner
• HbA1c Hemoglobin A1c
• HENT Head Ears Nose Throat
• HPI History of Present Illness
• INR International Normalized Ratio
• MMP Medication management plan
• MOHAP Ministry of Health and Prevention
• MRI Magnetic Resonance Imaging
• PD Patient Demographics
• PEFR Peak Expiratory Flow Rate
• PMH Past Medical History
• ROS Review of System
• SH Social History
• WBC White Blood Cell
1. Introduction

1.1 Background:

American College of Clinical Pharmacy (ACCP) defines clinical pharmacy

as “a health science discipline in which pharmacists provide patient care
that optimizes medication therapy and promotes health, wellness, and
disease prevention”. The practice of clinical pharmacy combination a
caring orientation with specialized therapeutic knowledge, experience
and judgment to ensure optimal patient outcomes. Additionally, the
clinical pharmacy has a responsibility to contribute to the generation of
new knowledge that enhances health and quality of life.

Clinical pharmacists care for patients in all health care settings. They
possess comprehensive knowledge of medications that are combined
with a foundational understanding of the biomedical, pharmaceutical,
socio-behavioral, and clinical sciences. The clinical pharmacist applies
evidence-based therapeutic guidelines, developing sciences, emerging
technologies, and relevant legal, ethical, social, cultural, economic, and
professional principles to achieve desired therapeutic goals. Clinical
pharmacists are the main source for scientifically valid information
and advice about the safe, appropriate, and cost-effective use of
medications. They have a responsibility to provide medication therapy
evaluations and recommendations to health care professionals and
patients to improve health outcomes. Besides, they provide daily follow-
up on the clinical effects of the treatment to attain desired outcomes.
Thus, the clinical pharmacist becomes a central element of the health
care team.

1.2 Scope and purpose of the manual:

These standards of practice manual include a recommended procedure

for the provision of clinical pharmacy services at the inpatient and
outpatient level. It contains a specific procedure for identifying,
classifying and documenting drug-related problems (DRP) and clinical
intervention. It should be used as a hands-on reference for the clinical
pharmacist, thereby helping to standardize the practice in all Ministry of
Health and Prevention (MOHAP) facilities and optimizing patient care.

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 1.3 Manual Objectives:
• Ensures that standardized clinical pharmacy services are provided
in all MOHAP hospitals.
• Clarifies roles and responsibilities of clinical pharmacists providing
pharmaceutical care.
• Ensuring the rational use of medicines to optimize patient outcomes.
• Provides details of how to perform clinical pharmacy activities.
• Serves as a source of guidance for the new clinical pharmacist.

2. Clinical pharmacy service components

2.1 Participation in multidisciplinary rounds and meeting

Attendance and participation of clinical pharmacists at multidisciplinary

round or meeting enables them to contribute in patient care through
the providing of medication information and influence the prescribing
decision. Additionally, this help to build a relationship with ward staff,
increase confidentiality, review inpatients regular medications, and early
resolve any medication issues in the admission.

2.2 Assessment of current medication management

Assessment of patient’s current medication to enhance the quality of

patient care and clinical outcomes.
Evaluation of the current medication management helps in:
• Ensure the medication order is appropriate with respect patient
specific considerations such as disease state, dosage form, route,
pregnancy, age, renal function and liver function.
• Ensure that the medication order is consistent with local prescribing
requirements and restrictions.
• Follow up non-formulary medicines orders and recommend formulary
equivalent when required.

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 Assessment of current medication management includes:
• Review all medication orders and administration records.
• Compare the patient’s current medicines to their medication
management plan and data from medical administration records,
laboratory results and therapeutic drug monitoring (TDM).
• Provide recommendation on the selection of medicines to support
therapeutic appropriateness.
• Identify and classify the DRP (Table.1)
• Identify the planned interventions(Table.2)
• Identify the level of acceptance of the Intervention proposals(Table.3)
• Identify the Status of the DRP (Table.4)
• Ensure all necessary medicine is available.
• Review medicines for cost-effectiveness.

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 Table 1. The Causes
(including possible causes for potential problems)
[N.B. One problem can have more causes]
Primary Domain Code Cause
V9.0
1. Drug selection C1.1 • Inappropriate drug according
to guidelines/formulary
The cause of C1.2 • Inappropriate drug (within
the (potential)
guidelines but otherwise
DRP is related
contra-indicated)
to the selection
of the drug (by C1.3 • No indication for drug
patient or health
C1.4 • Inappropriate combination of
professional)
drugs, or drugs and herbal
medications, or drugs and
dietary supplements
C1.5 • Inappropriate duplication of
therapeutic group or active
ingredient
C1.6 • No or incomplete drug
treatment in spite of existing
indication
C1.7
• Too many drugs prescribed for
indication
2. Drug form C2.1 • Inappropriate drug form (for
this patient)
The cause of the
DRP is related to
the selection of the
drug form
3. Dose selection C3.1 • Drug dose too low

C3.2 • Drug dose too high

The cause of the
DRP is related to • Dosage regimen not frequent
the selection of the C3.3 enough
dose or dosage
C3.4 • Dosage regimen too frequent

C3.5 • Dose timing instructions

wrong, unclear or missing

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 4. Treatment C4.1 • Duration of treatment too short
duration
C4.2 • Duration of treatment too long
The cause of the
DRP is related to
the duration of
treatment
5. Dispensing C5.1 • Prescribed drug not available

C5.2 • Necessary information not

The cause of the provided
DRP is related to
the logistics of the C5.3 • Wrong drug, strength or
prescribing and dosage advised (OTC)
dispensing process C5.4
• Wrong drug or strength
dispensed
6. Drug use process C6.1 • Inappropriate timing of
administration or dosing
The cause of the intervals
DRP is related C6.2 • Drug under-administered
to the way the
patient gets the C6.3 • Drug over-administered
drug administered C6.4 • Drug not administered at all
by a health
professional or C6.5 • Wrong drug administered
other carer, despite C6.6 • Drug administered via wrong
proper dosage
instructions (on route
label/list)

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 7. Patient related C7.1 • Patient uses/takes less drug
than prescribed or does not
The cause of the take the drug at all
DRP is related to
C7.2 • Patient uses/takes more drug
the patient and
than prescribed
his behaviour
(intentional or C7.3 • Patient abuses drug
non-intentional) (unregulated overuse)

C7.4 • Patient uses unnecessary drug

C7.5 • Patient takes food that

interacts
C7.6 • Patient stores drug
inappropriately
C7.7 • Inappropriate timing or dosing
intervals
C7.8 • Patient administers/uses the
drug in a wrong way
C7.9 • Patient unable to use drug/
form as directed
C7.10 • Patient unable to understand
instructions properly
8. Patient transfer C8.1 • No medication reconciliation at
related patient transfer.
C8.2 • No updated medication list
The cause of the
available.
DRP can be related
to the transfer of C8.3 • Discharge/transfer information
patients between about medication incomplete
primary, secondary or missing
and tertiary
care, or transfer C8.4 • Insufficient clinical information
within one care about the patient.
institution. C8.5 • Patient has not received
necessary medication at
discharge from hospital or
clinic.
9. Other C9.1 • No or inappropriate outcome
monitoring (incl. TDM)
C9.2
• Other cause; specify
C9.3 • No obvious cause

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 Table 2. The Planned Interventions
N.B. One problem can lead to more interventions
Primary Domain Code Intervention
V9.0
No intervention 10.1 • No Intervention
1. At prescriber level 11.1 • Prescriber informed only
11.2 • Prescriber asked for information
11.3 • Intervention proposed to prescriber
11.4 • Intervention discussed with
prescriber
2. At patient level 12.1 • Patient (drug) counselling
12.2 • Written information provided (only)
12.3 • Patient referred to prescriber
12.4 • Spoken to family member/caregiver
3. At drug level 13.1 • Drug changed to …
13.2 • Dosage changed to …
13.3 • Formulation changed to …
13.4 • Instructions for use changed to …

13.5 • Drug paused or stopped

13.6 • Drug started

4. Other intervention or 14.1 • Other intervention (specify)
activity
14.2 • Side effect reported to authorities

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 Table 3. Acceptance of the Intervention proposals
N.B. One status of acceptance per intervention proposal

Primary Domain Code Implementation

V9.0
1. Intervention accepted (by A1.1 • Intervention accepted and fully
prescriber or patient) implemented
A1.2 • Intervention accepted, partially
implemented
A1.3 • Intervention accepted but not
implemented

A1.4 • Intervention accepted, implementation

unknown
2. Intervention not accepted A2.1 • Intervention not accepted: not feasible
A2.2 • Intervention not accepted: no
(by prescriber or patient) agreement

A2.3 • Intervention not accepted: other

reason (specify)

A2.4 • Intervention not accepted: unknown

reason
3. Other (no information on A3.1 • Intervention proposed, acceptance
acceptance) unknown
A3.2
• Intervention not proposed

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 Table 4. Status of the DRP
N.B. This domain depicts the outcome of the intervention. One problem (or
the combination of interventions) can only lead to one level of solving the
problem
Primary Domain Code Outcome of intervention
V9.0
0. Not known O0.1 • Problem status unknown
1. Solved O1.1 • Problem totally solved
2. Partially solved O2.1 • Problem partially solved
3. Not solved O3.1 • Problem not solved, lack of cooperation of
patient
O3.2 • Problem not solved, lack of cooperation of
prescriber
O3.3 • Problem not solved, intervention not effective

O3.4 • No need or possibility to solve problem

2.3 Medication reconciliation

Medication reconciliation is an important part of medication

management and its intended to avoid medication error and medication
related problems at transition points in patient care. Moreover, it’s
intended to ensure the patient receives all intentional medication and to
prevent medication error, duplication, drug -drug interaction and drug-
disease interaction. Additionally, Medication reconciliation includes
documenting inconsistencies recognized between the medication
history and current medication orders and how these inconsistencies
were resolved. It should be undertaken in case of admission to hospital,
transfer between ward or care settings within the hospital, transfer from
the hospital to community or other organizations and during discharge.

Medication reconciliation involves (Flowchart.1):

• Obtaining and documenting the best possible medication history
• Confirming the accuracy of the medication history
• Comparing the medication history with the prescribed medicines and
follow-up inconsistencies
• Supplying verified information for ongoing care.

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 An interview with the patient/caregiver to obtain an accurate medical
history or verifying the history obtained by other health care professionals
is one of the main processes in patient care. If a reliable medical history
cannot be obtained from the patient/caregiver alternative sources
of patient information can be used such as previous prescriptions
(community pharmacy, discharge/outpatient), pre-admission clinic
records, general practitioners (GP) referral letter/other correspondence,
electronic records, e.g. pharmacy dispensing system, discharge
medication records and current medication chart/administration
records. A combination of information sources can be used to confirm
the medication history. Reviewing background information (Table.5)
before the interview allows patients to be prioritized and recognizes
issues to focus on during the interview. The information attained from
the interview should be documented and readily available to other
health provider involved in the patient care.

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 Flowchart 1. Medication Reconciliation Pathway

Adopted from The Society of Hospital Pharmacists of Australia. (2013). Journal of

Pharmacy Practice and Research,43(2), S3.

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

11
 Table 5. Background Patient Information
Age Consider the ability to metabolize or excrete medicines.
Gender, Consider impact of gender on medicine selection.
Height and weight Consider the BMI, BSA, measure of healthy versus unhealthy
weight and growth chart.
Allergy Consider any drug allergy moderate to severe symptoms.
Pregnancy or lactation Consider drug category list and safety.
status
Immunization status Consider vaccinations.
Ethnic background or Consider implications for medicine selection including
religion pharmacogenetic factors.
Social background Consider the impact on patient’s ability to manage their
medicines.
Details of regular GP Community pharmacy or other health professional as
appropriate.
Details of medication E.g. self-administering, nurse administers from dose
use administration aid, medicines crushed.
Ability to communicate E.g. cognitive function, language barriers, alertness,
mental acuity, psychological state, and requirements for
communication aids, e.g. glasses, hearing aids, need for
interpreter service.
Ability to take E.g. cognition, dexterity, swallowing ability.
medicines as
prescribed
Presenting condition Consider the possibility of adverse drug reactions, poor
adherence, inadequate dosing, inappropriate therapy as a
contributor to hospital presentation/morbidity.
Diagnosis. Consider health history, physical exam, and tests, such as
blood tests, imaging tests, and biopsies, may be used to help
make a diagnosis.
Previous medical Identify potential medicine and/or disease contraindications
history and ensure that management of the presenting complaint
does not compromise a prior condition. Consider therapies
for prior conditions that may have been omitted.

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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Relevant laboratory Focus on findings that will affect decisions regarding
or other findings (if medicines, such as:
available)
• Renal function
• Electrolytes
• Liver function
• Full blood count
• Cardiac markers
• General observations
• Relevant previous therapeutic drug monitoring results.
Adopted from The Society of Hospital Pharmacists of Australia. (2013). Journal of
Pharmacy Practice and Research,43(2), S3.

2.4 Clinical review

The clinical review is the review of the patient-specific clinical

information to assess their response to medication therapies and to
identify and manage potential or actual medicines related problems. The
clinical review must be undertaken in conjugation with an assessment
of the current medication management as a routine activity. Patient-
specific clinical information may include routine observation such as
temperature and blood pressure, weight, urine output, fluid balance,
biochemistry results, hematology results, microbiology results and
radiological investigations.

2.5 Therapeutic drug monitoring

TDM involves measuring of drug concentrations in the body fluids,

interpreting and monitoring the results to optimize drug therapy and
minimize toxicity.
TDM is indicated for patients being treated with medicines with
specific criteria such as:
• Narrow therapeutic index
• High risk
• Significant pharmacodynamics variability
• Significant adverse effect profile
• Significant interactions

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 Patient target groups include:
• Renal or hepatic impairment patient
• Dialysis and hemofiltration patient
• Uncompensated cardiac dysfunction
• Burned patients, cystic fibrosis and polymorphisms
• Geriatric and pediatric (specially neonates) patients
• Pregnant
• Obese and undernourished
Factors to consider when interpreting the results:
• Drug, dose, dosage and dosing schedule
• Route of administration
• Indication
• TDM reason
• Current medication regimen duration
• Last dose time
• Sampling time
• Previous drug monitoring
• Other relevant laboratory results
• Patient specific factors such as renal and hepatic function
• Pharmacokinetic and pharmacodynamics properties of the drug
• Possibility of sampling or measurement error
• Environmental factors such as smoking
Example of medications that TDM can be requested
Amikacin Vancomycin Digoxin
Gentamicin Theophylline Phenytoin

Figure 1. Process of Therapeutic Drug Monitoring

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 2.6 Anagement of adverse drug reaction

Prevent, detect and report adverse drug reaction (ADR) to ensure the
safety of medication dispensed to the patient, minimize and/or prevent
drug induced morbidity and mortality and this can be attained by:
• Avoid using a drug that known to produce predictable adverse drug
reaction when there is equally effective and safer alternative available
in the formulary.
• Ensure appropriate dosage form or regimen by identifying the patient
who required close monitoring.
• Identify patients with hypersensitivity to a specific medication or class
of medicines.
• Ensure that patients not exposed to unnecessary risk through
unnecessary medication or through drug interaction with medication
or food or drinks.
• Ensure that patients receive counseling on medication and device
usage, lifestyle modification and drug adherence programs.
Target group who required close monitoring include:
• Previously experienced ADRs
• Multiple diseases
• Polypharmacy
• Geriatric and pediatric patients
• Renal and hepatic impairment patients
• Those treated with medicines known to have high incidence of adverse
effects
• Those treated with medicines know to be associated with serious
adverse effects
• Those treated with narrow therapeutic index drug
• Those with critical abnormal investigation results
Clinical pharmacists have to encourage medical staff, patient and
caregiver to report any suspected ADR in pharmacovigilance form.
ADRs should be documented in the electronic medical record to avoid
re-exposure of the patient who has already experienced an ADR. They
have to review the relevant literature and if possible, consult with other
health professionals when a particular drug is suspected as the cause
of ADR.

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 Comprehensive adverse reaction details include:
• Description of the reaction
• Time of onset
• Duration of reaction
• Complications and sequelae
• Treatment and consequence of treatment
• Relevant investigation results

2.7 Medication management plan

Medication management plan (MMP) is continuing plan developed and

used by healthcare professional in collaboration with patient/caregiver
to manage patients medicine. It assists in transfer and discharges care
planning. If possible, an MMP is completed for all patient but if it cannot
be completed for all patients.
Patients at high risk for medical related problems should be
prioritized and they are including:
• Geriatric (65 years or older)
• Take more than 12 doses of medicines per day
• Patient has clinically significant changes to their medicines or treatment
plan within the last 3 months
• Patient has suboptimal response to treatment with medicines
• Patient has Impaired renal or hepatic function patients
• Patient has had multiple admissions to healthcare facilities
• Patient has experienced a transition of care, and his or her regimen
has changed
• Patient is receiving care from more than one prescriber
• Patient is taking five or more chronic medications (including prescription
and nonprescription medications, herbal products, and other dietary
supplements)
• Patient has at least one chronic disease or chronic health condition
(e.g., heart failure, diabetes, hypertension, hyperlipidemia, asthma,
osteoporosis, depression, osteoarthritis, chronic obstructive pulmonary
disease)
• Patient has laboratory values outside the normal range that could be
caused by or may be improved with medication therapy
• Patient has demonstrated no adherence (including underuse and

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

16
 overuse) to a medication regimen
• Patient has limited health literacy or cultural differences, requiring
special communication strategies to optimize care
• Patient wants or needs to reduce out-of-pocket medication costs •
Patient has experienced a loss or significant change in health plan
benefit or insurance coverage
• Patient has recently experienced an adverse event (medication or
non-medication-related) while receiving care
• Patient is taking high-risk medication(s), including narrow therapeutic
index drugs (e.g., warfarin, phenytoin, methotrexate) • Patient self-
identifies and presents with perceived need for MTM services
The main component of MMP includes:
• Medication therapy review (MTR)
• Personal medication record (PMR)
• Medication-related action plan (MAP)
• Intervention and/or referral
• Documentation and follow-up

2.8 Provision of medical information to healthcare professionals

The clinical pharmacist has a responsibility to provide medicines

information to health professionals to enhance the prescribing,
administration, monitoring and use of medicines for the patients.
They require critical literature evaluation skills, an awareness and
understanding of the available medicine’s information resources and their
limitations and use effective communication skills to provide accurate and
relevant medicines information. As well, the clinical pharmacist should
have access electronic medical records and to up-to-date medicines
information to base their clinical pharmacy service on.
Resources of information may include:
• Information on electronic medical record
• Local or International Therapeutic Guidelines (where local guidelines
are not available yet)
• Medical literature accessed online
• Shared resources with the Drug Information Center

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 2.9 Provision of medical information to the patient (Patient
counseling)

To achieve safe and effective use of medicines, clinical pharmacists must

provide comprehensive information and advice to patients/caregiver.
See Flowchart 2.
• The clinical pharmacist must provide information on:
• Generic and brand names of the medicine, strength and physical
description
• Therapeutic purpose and predictable action
• Duration of treatment
• Administration advice
• Storage
• Common adverse effects and action required if they occur
• Precautions and relevant interactions
• Self-monitoring therapy techniques
• Follow-up plan
• Action to be taken following a missed dose
• Use of adherence aids
• Stopped medicines
• New medicines or medicines with changed dose or dose forms
• Where a brand/formulation change has been made

2.10 Documenting clinical activities

Documenting clinical activities is an important element of providing clinical

pharmacy service and it includes recording patient-specific information,
clinical interventions, and quality improvement activities. It information
shall be collected and recorded in the electronic medical record in order
to form permanent records.

2.11 Prioritizing clinical pharmacy services

Good time management is important as there is only a limited time on

the ward. Ideally, every patient on the ward should be reviewed daily; but,
that’s not always possible, thus patients must be prioritized to be seen by
the clinical pharmacist.

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 Patients that should receive the highest priority for clinical
pharmacy review include:
• New admissions
• Pediatrics and geriatrics
• Patients on multiple drugs (polypharmacy)
• Patients with a drug-related admission
• Cancer patients
• Organ transplantation patients
• Autoimmune diseases patients
• Critically ill patients
• Patients on “high-risk” medications

2.12 Participating in research (according to MOHAP regulations)

Clinical pharmacist contributing in research should focus on therapeutics,

pharmacy practice, health service and quality improvement to promote
development in the pharmacy profession and improve patient’s health
outcome. Participating in research includes involvement in the design,
conduct and analysis of research.

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

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 Flowchart 2. Example of Patient Education Process
(Warfarin)
Identify Brand and Generic
Start Address Patient Name of Drugs, Dose, Identify the Specific Reasons
Formally Duration, Administration the Patient is on the drug
and storage

Get patient’s knowledge about

taking the drug warfarin

End
Explain that the drug Does patient know
prevents blood clots No
Document activation the purpose of the
by slowing the clotting drug?
in chart process.
Yes
Thanking Patient
Explain the symptoms of
bleeding (e.g. bloody nose,
Porvide printed
blood in the urine, bruises, etc.)
educational Materials

Review information Explain that the Does the patient

that is not patient should know what to
understood contact their doctor No
do if they notice
No immediatly. bleeding?
Yes
Yes Does the patient
understand the Ask the patient to discuss all
information? medications (Including OTCs)
with their healthcare providers.

Summarize the key

points(purpose, Ask patient to inform No Does the patient
interations, how to their Doctor or the know what to do if
handle a miss dose, etc.) anticoagulation Clinic they miss dose?

Yes
Explain dietary restrictions of eating a
consistent, moderate diet of vegetables Stress the importance of
and foods high in vitamin K (e.g. spinach, follow-up and blood draw
broccoli, garlic, onion, [Link].) appointment.

Adopted from [Link]. (2017). Clinical Pharmacist.

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3. Patient care process

The main process of patient care in the clinical practice (Figure 2):

Step1: Assessment of the patient

Step 2: Evaluation of medical therapy

Step 3: Development and implementation of a plan of care

Step 4: Documentation of clinical intervention

Step 5: Follow-up evaluation and medication monitoring

Figure 2. Process of patient care in the clinical practice

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 3.1 Assessment of the patient through reviewing the patient medical
record and meeting with the patient or her caregiver to determine the
patient medical status, medical history, current medication, adherence,
allergies and experiences with medication therapy. The information
collected can be used to identify the clinical problem, develop the goal
of therapy and recognize monitoring parameters.

3.2 Evaluation of the current medical therapy based on a health

condition, assessing the effectiveness and safety of each medication,
recognize the active or potential DRP.

3.3 Development and implementation of a plan of care (Clinical

intervention): Clinical pharmacist develops and implements
comprehensive medication management plan in collaboration with
other healthcare provider team after reviewing the patient’s medical
problem and assessing the medication therapy in order to optimize
medication therapy and achieve patient-specific outcomes. Moreover, a
clinical pharmacist must educate the patient or caregivers the care plan
and promote patient adherence.
The aims of clinical interventions are to:
• Encourage communication between clinical pharmacist, patients and
healthcare providers.
• Optimize medication therapy and improve therapeutic response.
• Reduce DRP occurrence.
• Reduce hospital length of stay.
• Reduce healthcare cost.
• Minimize/Stop medication errors occurrence.
• Drug monitoring and utilization

3.4 Documentation of clinical intervention:

Clinical intervention should be recorded and appropriate medical

recording system (electronic system integrated with the patient medical
record) should be used.

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 The recorded information must include:
• Active or potential DRP and assessment of each problem
• DRP and Intervention Classification
• Recommendation and clinical intervention
• Communication with patient’s prescriber
• Outcome of intervention

3.5 Follow-up evaluation and medication monitoring:

In collaboration with another healthcare team; the clinical pharmacist

performs follow-up evaluation to continually assess patient outcomes and
ensure that the individual targets are achieved. All follow-up evaluation
and medication monitoring must be included in the documentation.
Parameters which might be used for monitoring disease progress
and treatment response in cooperation with healthcare team may
include:
• Clinical signs
• Patient self-reporting of symptom
• Physiological measurements such as blood pressure and peak
expiratory flow rate (PEFR)
• Biochemical results such as serum potassium, creatinine, thyroid
function tests, serum lipids, Hemoglobin A1c (HbA1c) for diabetes.
• Hematological results such as hemoglobin, International Normalized
Ratio (INR), or prothrombin time.
• Serum concentration of some medications such as phenytoin.

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 Table 6. Examples of Optimal Care Opportunities
Description of Optimum Care Examples of Recommendations
Intervention Type
Untreated indication: • Statins for patients with coronary artery disease
and low-density lipoprotein cholesterol above
Recommendation to start
goal
a medication for a medical
condition that is currently
• Angiotensin-converting enzyme inhibitor for
untreated but considered a
patient with diabetes and microalbuminuria
standard of care
Optimal drug: • Glipizide is preferred over glyburide in patient
aged 71 years with chronic kidney disease.
Recommendation to replace
a current medication
• Switch from a long-acting benzodiazepine
with a more appropriate
(flurazepam) to a shorter-acting benzodiazepine
medication based on patient
such as oxazepam in an elderly patient with
characteristics, comorbidities,
insomnia.
and pharmacokinetic or other
characteristics of the medication
Adverse drug reactions: • Avoid pioglitazone or rosiglitazone in a patient
with stage 3 congestive heart failure.
Identification of a potential or
actual adverse drug reaction • Metformin should not be used among chronic
kidney disease patients with an estimated
glomerular filtration rate (eGFR) <30 mL/
min/1.73 m2, because of an increased risk of
lactic acidosis.
Nonadherence: • Address nonadherence with patients with
osteoporosis who have stopped filling their
Evidence that the patient is prescription for alendronate.
not taking the medication as
prescribed • Address nonadherence with a patient prescribed
a statin whose cholesterol has increased
dramatically yet not been addressed at previous
appointments.
Drug monitoring: • Order a serum potassium determination for
patient started on hydrochlorothiazide more
Identification of inappropriate than 1 year ago.
medication monitoring and
recommending appropriate • Order thyroid-stimulating hormone
medication monitoring determination for a patient with a change in
levothyroxine dose more than 3 months ago who
does not have current blood work done.

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 Drug interactions: • Assure that patient treated for hypothyroidism
and starting on calcium supplement does not
Identification of clinically relevant take calcium and levothyroxine together.
drug interactions or warning of
potential drug interactions • Limit acetaminophen dosing to less than 2 gm
per day in patient on chronic carbamazepine,
which can induce acetaminophen conversion to
a toxic metabolite.
Subtherapeutic dose: • Increase angiotensin-converting enzyme
inhibitor dose to goal dose per congestive heart
Recommendation for alternative failure standards.
dosing for someone on a sub-
therapeutic dose • Increase calcium and vitamin D supplement to
achieve recommended total daily intake.
Supradose: • Starting dose of niacin extended-release tablets
at 1,000 mg is unlikely to be tolerated by the
Recommendation for alternative patient; suggest 500 mg at bedtime.
dosing for identification of a
patient prescribed a dose that is • Patient taking conjugated estrogens, 0.9 mg
inappropriately high or should daily—attempt titrating estrogen dose to
ideally be titrated downward minimum effective dose for postmenopausal
symptoms.

No indication: • Discontinue proton pump inhibitor in a patient

recently discharged from the hospital with a new
Recommendation to discontinue prescription for a proton pump inhibitor without
a medication that appears to lack a gastrointestinal condition.
an indication
• Discontinue 1 mg folic acid daily supplement in
a patient who discontinued oral methotrexate
more than 1 year ago.
Cost: • Change prescription to 1 tablet of a higher
strength instead of multiple tablets of lower
Recommendation for an equally strength to achieve the dose (e.g., 40 mg of
effective but less expensive atorvastatin twice daily to 80 mg of atorvastatin
medication once daily).

Adopted from Altavela, Jones, & Ritter, 2008, Journal of Managed Care Pharmacy, 14(9), 831-
843.

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4. Component of patient’s medical record

The medical record can be divided contain five primary components,

including medical history, laboratory and diagnostic test results, problem
list, clinical notes and treatment notes which must be reviewed by the
clinical pharmacist.

4.1 Medical history

The medical history includes the following components:

4.1.1 Patient demographic (PD)
This section includes patients name, birth date, address, gender, contact
number, race, religious, marital status.
4.1.2 Chief complaint (CC)
It represents the primary reason the patient is presenting for care and it’s
usually expressed using patients own ward, it includes the symptoms the
patient currently experiencing.
4.1.3 History of present illness (HPI)
It expands upon the CC and it describes patient symptoms in detail,
previous treatment for the CC and previous diagnostic test results.
4.1.4 Past medical history (PMH)
It includes a list of past and current medical conditions, past surgical
history and hospitalization.
4.1.5 Family history (FH)
It includes a description of family age, status, chronic medical conditions.
4.1.6 Social history (SH)
This section includes personal characteristic such as the use of alcohol,
tobacco, illicit drug use. It may also include patient dietary habit, exercise
routine, use of caffeine, occupation, sexual practices.
4.1.7 Allergies
It includes any allergic reaction a patient has had to medication, foods,
vaccines, stings and contrast media.
4.1.8 Medication history
It includes a list of patient’s current medication.
4.1.9 Review of system (ROS)
This section represents subjective feelings or symptoms the patient is
experiencing and it is conducted for each organ system and in head-to-
toe order. The typical order of ROS is provided in the table.4
4.1.10 Physical examination (FE)
It includes the objective information obtained from practitioner’s
examination of the patients.

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 Table 7. Order and Contents of ROS
Body system Example of contents

General • Overall feelings of wellness, weight gain or loss, fever, chills,

night sweats, fatigue, weakness

Skin • Change in color, dryness, hair loss, rashes, pruritis, bruising,

bleeding

Eye • Change in vision (blurry vision, double vision, floaters), trauma,

use of corrective lenses
HENT • Headache, trauma, syncope, change in hearing, tinnitus, vertigo,
discharge, stuffiness, difficulty

Mouth • Swallowing
Neck • Soreness, gum bleeding, issues with teeth
Respiratory system • Pain, stiffness, swelling, lumps
Cardiovascular system • Shortness of breath, dyspnea, wheezing, cough (dry vs.
productive), orthopnea, hemoptysis
Gastrointestinal system • Chest pain, palpitations

• Nausea, vomiting, constipation, diarrhea, abdominal

Genitourinary system • pain, hematemesis, melena, hematochezia, jaundice

• Urinary frequency, urgency, hesitancy, dysuria, hematuria,

incontinence, pain

• Female: vaginal discharge, discomfort, itching, characteristic

of menstrual periods
Nervous system • Male: erectile dysfunction, lesions
Abbreviation: HENT: Head Ears Nose Throat

Adopted from Spooner & Pesaturo. (2013). Fundamental Skills for Patient Care in Pharmacy
Practice, 37.

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 4.2 Laboratory test results

This section may include, but not limited to, complete blood count (CBC),
cardiac enzyme, serum drug concentrations, liver function tests, blood or
other body fluids culture.

4.3 Diagnostic test results

This section includes results of electrocardiograms, echocardiograms,

ultrasounds, computed tomography (CT) scans, magnetic resonance
imaging (MRI) scans, X rays, and so on.

4.4 Problem list

It includes the issue that requires management in an individual patient. It’s

dynamic and it may change from day to day because patient diagnoses
and individual characteristics can change rapidly especially in the acute
setting.

4.5 Clinical notes

4.5.1 Progress note
Daily notes that document an updated medical history, problem list and
plan.
4.5.2 Consultation notes
Notes that document by the specialist (e.g., cardiologist, gastroenterologist)
4.5.3 Transfer note
4.5.4 Discharge summary
Provides a snapshot of the patient hospital course, including treatments
provided, follow-up plan and a list of discharge medications.

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5. Clinical pharmacist’s competency standards in patient

care

The clinical pharmacist must have a list of competencies in order to

assess their abilities to do clinical responsibilities and measure their
performance. The following competencies must be achieved by a clinical
pharmacist:

5.1 Professional and ethical practice

• Apply and monitor standards of practice at team level and beyond
the team
• Manage quality and safety

5.2 Communication, collaboration and teamwork

• Use effective communication skills to gain the collaboration of patients,
colleagues and other healthcare providers
• Demonstrate ability to work with a teamwork and accept expert advice
through consultation within the workplace
• Extend the boundaries of service delivery across more than one team

5.3 Leadership and management

• Recognize strategic situation and contribute to strategic planning
• Recognize the pharmacist role in clinical governance
• Recognize and contribute to the vision for professional services
• Contribute to innovation and service improvement
• Demonstrate ability to motivate self and others
• Assist implementation of national health care priorities
• Recognize and contribute to the effective resources management
• Recognize and resolve risk management using professional policy
and procedure
• Encourage improved performance of the team members
• Recognize the principle of successful project management and
manage simple projects
• Recognize the principle of change management
• Act as a role model and effective mentor for others

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 5.4 Promote and contribute to optimal use of medicines
• Acquire expert knowledge and skills and capable to plan, manage,
monitor and review patient care
• Use professional judgment in assessing clinical situations
• Deliver responsible and flexible patient care
• Use professional autonomy and display ability to follow legal, ethical
and organizational policies and procedure.

5.5 Critical analysis, research and education

• Conduct education and training
• Links practice and education
• Understand current educational policies in health service
• Demonstrate ability to critically evaluate literature sources
• Work as member of research team
• Design and deliver research projects
• Apply research into practice
• Supervise postgraduate student s researc

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6. Clinical Pharmacy Competencies

Pharmacist Clinical pharmacist Specialist Consultant

(Resident)
Norm of Competency level:

Demonstrate Implementation of Comprehensive Possess a defined

knowledge, the basic areas of acquaintance or body of knowledge,
sciences and knowledge, skills, and discipline-specific clinical skills,
performance attitudes considered knowledge, skills and professional
in reaching essential for the practice and attitudes attitudes, which are
objectives of of clinical pharmacy. that needed to directed to effective
clinical pharmacy. deliver high level patient-centered
clinical pharmacy care, with the art of
services and clinical reasoning
address specialized and interpretation
objectives in to lead and coach
patients care. clinical pharmacists
toward effective
clinical pharmacy
practices.

Name of the technical competency: Direct Patient Care

Able to learn and Assess patients, Specialty High level of clinical

apply how to including identifying assessment of reasoning and
assess patients, and prioritizing patients, in various expert in guiding
including patient problems and or specific disease comprehensive
identifying and medication-related areas, including assessment of
prioritizing needs. identifying and patients for effective
patient problems prioritizing patient clinical outcomes.
and medication- problems and
related needs. medication-related
needs.
Able to address Evaluate drug therapy Reflecting a higher Lead and coach
and apply the for appropriateness, level of evaluating clinical evaluation
objectives of effectiveness, safety, drug therapy for of therapies for
evaluating drug adherence, and appropriateness, appropriateness,
therapy for affordability. effectiveness, effectiveness, safety,
appropriateness, safety, adherence, adherence, and
effectiveness, and affordability in affordability.
safety, adherence, various or specific
and affordability. disease areas.

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Able to address Intervene in therapeutic Reflecting a higher Lead and coach
how to intervene plans and address level of intervening intervening
in therapeutic medication-related therapeutic plans therapeutic plans
plans and address problems. and address and address
medication- medication-related medication-related
related problems. problems in problems.
various or specific
disease areas.
Able to address Follow-up on and Reflecting a higher Lead and coach
how to follow-up monitor the outcomes level of follow-up follow-up on
on and monitor of therapeutic plans on and monitor and monitor the
the outcomes of the outcomes outcomes of
therapeutic plans of therapeutic therapeutic plans.
plans in various
or specific disease
areas.
Able to Collaborate and Reflecting a Collaborate
address how to teamwork with other higher level of assertively, lead
collaborate with members of the health collaboration and coach with
other members care team to achieve and effective other health care
of the health care optimal patient teamwork with team members and
team to achieve outcomes across the other members leaders to achieve
optimal patient continuum of care. of the health care optimal patient
outcomes across team to achieve outcomes across the
the continuum of optimal patient continuum of care.
care. outcomes across
the continuum of
care.
Able to address Apply knowledge Reflecting a Identify, develop
the knowledge of the roles and higher level of and disseminate
of the roles and responsibilities of understanding knowledge for the
responsibilities of other health care team of knowledge clinical pharmacists
other health care members to patient of the roles and about the roles and
team members to care. responsibilities of responsibilities of
patient care. other health care other health care
team members to team members to
patient care. patient care.

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Pharmacotherapy knowledge

Able to Demonstrate and apply High level of in- Able to lead and
demonstrate in-depth knowledge depth application coach to ensure the
how to apply of pharmacology, of knowledge of application of up-
knowledge of pharmacotherapy, pharmacology, to-date knowledge
pharmacology, pathophysiology, pharmacotherapy, of pharmacology,
pharmacotherapy, and the clinical signs, pathophysiology, pharmacotherapy,
pathophysiology, symptoms, and natural and the clinical pathophysiology,
and the clinical history of diseases and/ signs, symptoms, and the clinical
signs, symptoms, or disorders. and natural history signs, symptoms,
and natural of diseases and/ and natural history
history of diseases or disorders, in of diseases and/or
and/or disorders. various or specific disorders.
disease areas.

Able to achieve Locate, evaluate, Higher level Able to develop,

how to locate, interpret, and assimilate skills to locate, lead, coach and
evaluate, scientific/clinical evaluate, interpret, monitor the
interpret, and evidence and other and assimilate approaches to
assimilate relevant information scientific/clinical locate, evaluate,
scientific/clinical from the biomedical, evidence and interpret, and
evidence and clinical, epidemiological, other relevant assimilate scientific/
other relevant and social-behavioral information from clinical evidence
information from literature. the biomedical, and other relevant
the biomedical, clinical, information from the
clinical, epidemiological, biomedical, clinical,
epidemiological, and social- epidemiological, and
and social- behavioral social-behavioral
behavioral literature, in literature.
literature. various or specific
disease areas.
Able to achieve Use scientific/clinical Higher level of the Able to lead and
the use of evidence as the basis for use of scientific/ coach to ensure use
scientific/clinical therapeutic decision- clinical evidence of scientific/clinical
evidence as making. as the basis for evidence as the
the basis for therapeutic basis for therapeutic
therapeutic decision-making, decision-making.
decision-making. in various or And provide relevant
specific disease feedback.
areas.

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Acquire Maintain and enhance Higher level Possess, provide
harmacotherapy pharmacotherapy of general or and maintain
knowledge, knowledge, including specialized identified body of
including academic degree, pharmacotherapy pharmacotherapy
academic degree, recertification or other knowledge, knowledge,
certification or appropriate methods academic degree, including advanced
other appropriate of self-assessment and certification or level of academic
methods of self- learning. other appropriate degree, certification
assessment and methods of self- or other appropriate
learning. assessment and methods of self-
learning. assessment and
learning.
Commit to Commit to excellence Commit to Commit to
excellence and and lifelong learning. excellence and excellence and
lifelong learning. lifelong learning. lifelong learning.
Address the skills Demonstrate skills of Higher level of Higher level of skills
of self-awareness, self-awareness, self- skills of self- of self-awareness,
self-assessment, assessment, and self- awareness, self- self-assessment, and
and self- development. assessment, and self-development.
development. self-development.
Systems-based care and population health

Able to identify Use health care delivery Expert use of Ensure the
the use of health systems and health health care appropriate use
care delivery informatics in MOHAP delivery systems and participate in
systems and to optimize the care of and health development of
health informatics individual patients and informatics health care delivery
in MOHAP to patient populations. of MOHAP to systems and health
optimize the optimize the informatics in
care of individual care of individual MOHAP to optimize
patients patients the care of individual
and patient and patient patients and patient
populations. populations. populations.
Participate (under Participate in identifying Higher ability Analyze, plan,
supervision) systems-based errors of identifying lead and coach
in identifying and implementing systems-based identifying systems-
systems-based solutions. errors and based errors
errors and collaboration in and ensure the
implementing implementing appropriateness and
solutions. solutions. implementation of
solutions.

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Able to address Resolve medication- High level of Lead and coach
the basics related problems ability to resolve the mechanism
of resolving to improve patient/ medication-related of resolving
medication- population health and problems, in medication-related
related problems quality metrics. various or specific problems to
to improve disease areas, to optimize patient/
patient/ improve patient/ population health
population health population health and ensure quality
and quality and quality metrics are met.
metrics. metrics.
Acquire the Apply knowledge of Apply Expert grasp of
knowledge of pharmacoeconomics knowledge of pharmacoeconomics
rmacoeconomics and risk-benefit analysis harmacoeconomics knowledge
and risk-benefit to patient-specific and/ and risk-benefit and assure the
analysis to or population-based analysis to patient- application of risk-
patient- care. specific and/or benefit analysis for
specific and/or population-based patient-specific and/
population-based care. or population-based
care. care.
Able to follow Participate in Able to supervise Develop, lead and
the processes developing processes and participate coach processes to
to improve to improve transitions in developing improve transitions
transitions of care. of care. processes to of care.
improve transitions
of care.
Able to Comply with quality Participate in Plan & develop, lead
follow quality improvement processes designing quality and coach quality
improvement to improve medication improvement improvement
processes use. processes processes to improve
to improve to improve medication use.
medication use. medication use.
Learn how to Identify and implement Identify and Maintain and
identify and strategies for personal implement develop up-to-
implement steps improvement through strategies date strategies
for personal continuing professional for personal for personal
improvement development. improvement improvement
through through through continuing
continuing continuing professional
professional professional development.
development. development.

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Able to blend in Provide professional Provide and Plan & develop, lead,
the atmosphere education to students, supervise coach and assess to
of professional trainees, or other health professional ensure the provision
education with professionals. education to professional
other students, students, trainees, education to
trainees, or or other health students, trainees,
other health professionals. or other health
professionals. professionals.
Communication

Communicate Communicate Communicate Communicate

effectively with: effectively with: effectively with: effectively with:
trainers, patients, trainers, patients, trainers, patients, leaders, trainees,
caregivers, caregivers, families, and caregivers, families, teams, patients,
families, and laypersons of diverse and laypersons caregivers, families,
laypersons backgrounds. Other of diverse and laypersons of
of diverse health professionals and backgrounds. diverse backgrounds.
backgrounds. stakeholders. Other health Other health
Other health professionals and professionals and
professionals and stakeholders. stakeholders, and
stakeholders. handle awkward
situation wisely.
Address ability Provide clear and Provide clear and Provide clear
to provide clear concise consultations concise in-depth and concise
and concise to other health consultations consultations, with
consultations professionals. to other health different levels of
to other health professionals. complexity, to health
professionals. professionals.
Able to acquire Use professional written Address high level Use and coach for
the knowledge on communications that of professional advanced level of
how to develop are appropriate to the written professional written
professional audience. communications communications
written that are that are appropriate
communications appropriate to the to the audience.
that are audience.
appropriate to the
audience.

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Demonstrate Use verbal Use verbal Assure the
ability use verbal communications communications use of verbal
communications tailored to varied clinical tailored to varied communications
tailored to varied and patient-specific clinical and tailored to varied
clinical and environments. patient-specific clinical and
patient-specific environments. patient-specific
environments. environments.
Demonstrate Communicate with Communicate Communicate
ability to appropriate levels with high levels as expert with
communicate of assertiveness, of assertiveness, advanced levels
with appropriate confidence, empathy, confidence, of assertiveness,
levels of and respect. empathy, and confidence,
assertiveness, respect. empathy, and
confidence, respect.
empathy, and
respect.
Professionalism

Uphold the Uphold the highest Uphold the Uphold and

highest standards standards of integrity highest standards coach the highest
of integrity and and honesty. of integrity and standards of integrity
honesty. honesty. and honesty.
Demonstrate Serve as a credible role Serve as a credible Serve as a credible
the values and model for students, role model leader for students,
behaviors of a trainees, and colleagues and guide for trainees, and
professional. by exhibiting the values students, trainees, colleagues by
and behaviors of a and colleagues exhibiting the values
professional. by exhibiting and behaviors of a
the values and professional.
behaviors of a
professional.
Demonstrate Advance clinical Advance clinical Advance clinical
engagement pharmacy through pharmacy through pharmacy
in professional professional professional through leading
stewardship stewardship, and stewardship, and and coaching
programs and all active engagement in active engagement professional
different future professional societies. in professional stewardship, and
training. societies. active engagement
in professional
societies.

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Quality, research and development

Able to acquire Design and deliver Design and deliver Design and deliver
the knowledge on research projects to research projects research projects to
how to design and address gaps in the to address gaps in address gaps in the
deliver research evidence base. the evidence base. evidence base.
projects.
Acquire the Critical analysis High level of Advanced level
knowledge of critical analysis of critical analysis
Critical analysis. (Undertake critical (Undertake (Undertake critical
evaluation activities) critical evaluation evaluation activities)
activities)
Demonstrate Participate in research Participate and Lead and manage
ability to conduct research research activities
help others
undertaking
research
Demonstrate Contribute to Contribute Contribute to
innovative innovation and service to innovation innovation and
attribute. development and service service development
development
Address the Participate in quality Participate/ Lead and coach the
knowledge on accreditation processes support clinical quality accreditation
health quality & risk management. pharmacists processes & risk
accreditation in quality management.
processes & risk accreditation
management. processes & risk
management.

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7. References
• Advanced Pharmacy Practice Framework Steering Committee. (2012). An
advanced pharmacy practice framework for Australia. Canberra: APPFSC.
• Altavela, J. L., Jones, M. K., & Ritter, M. (2008). A prospective trial of a clinical
pharmacy intervention in a primary care practice in a capitated payment
system. Journal of Managed Care Pharmacy, 14(9), 831-843.
• American College of Clinical Pharmacy. (2014). Standards of practice for
clinical pharmacists. Pharmacotherapy, 34(8), 794.
• Burke, J. M., Miller, W. A., Spencer, A. P., Crank, C. W., Adkins, L., Bertch, K. E.,
... & Valley, A. W. (2008). Clinical pharmacist competencies. Pharmacotherapy:
The Journal of Human Pharmacology and Drug Therapy, 28(6), 806-815.
• Burns, A. (2008). Medication therapy management in pharmacy practice: core
elements of an MTM service model (version 2.0). Journal of the American
Pharmacists Association, 48(3), 341-353.
• [Link]. (2017). Clinical Pharmacist. Available at: [Link]
rid=1133991078312_163954543_347/Clinical%[Link].
• Europe, P. C. N. (2006). PCNE Classification for Drug related problems.
Pharm Care Netw Eur.
• Francis, J., & Abraham, S. (2014). Clinical pharmacists: Bridging the gap
between patients and physicians. Saudi Pharmaceutical Journal, 22(6),
600-602.
• Ministry of Health. (2013). Clinical Pharmacy Practice Manual for Fijis Hospital
Pharmacy Departments.
• National Health Service in Scotland. (1999). Clinical pharmacy practice
in primary care a framework for the provision of community-based NHS
pharmaceutical services.
• Pharmaceutical Society of Australia. (2011). Standard and guidelines for
pharmacists performing clinical interventions.
• SHPA Committee of Specialty Practice in Clinical Pharmacy. (2005). SHPA
standards of practice for clinical pharmacy. Journal of Pharmacy Practice
and Research, 35(2), 122.
• Spooner, L. M., & Pesaturo, K. A. (2013). The Medical Record. Fundamental
Skills for Patient Care in Pharmacy Practice, 37.
• Standard Operating Procedures Manual for the Provision of Clinical Pharmacy
Services in Ethiopia. (2015).
• The Society of Hospital Pharmacists of Australia. (2013). Standards of
Practice for Clinical Pharmacy Services. Journal of Pharmacy Practice and
Research,43(2), S3.
• Walker, R. (2011). Clinical pharmacy and therapeutics. Elsevier Health
Sciences. Fifth edition.
• PCNE Classification for Drug-Related Problems V9.00.

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8. Appendix: Job Description Forms

Job Description Form

Details of Tasks
Job Title Clinical pharmacist

Job Code

Functional Category Job Evaluation and Presidency of the Council of

Characterization System: Ministers: Specialized and

technical and professional professional

Job Grade Third

Direct Chairman Head of Clinical Pharmacy Services Section

Administration Pharmacy Administration

Career Path Specialist professional

Functional family Health and safety

Sub-functional family Pharmacy

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 The Overal Objective of the Job
Provide clinical pharmacy services to patients and interact effectively with doctors and nurses
to provide high quality therapeutic services.

Job Dimensions
Numbers of Direct Number of Units Number of Employees
Adminitrative Staff
of the Incumbent
Indirect

Financial Powers In accordance with the Manual of Government Financial

Procedures and the powers vested in the Federal Authority.

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 Key Responsibilities

Specialized Tasks Operational performance

indicators
1 Practicing the clinical pharmacy Percentage of completion of tasks
profession in various therapeutic areas assigned to him according to work
in accordance with the Ministry’s policies plans
and internationally approved standards for
clinical pharmacy practices
2 Participate in meetings and rounds of Participation rate in meetings and
medical teams about patients in the internal rounds of medical teams
departments of the hospital and encourage
the use of appropriate treatments for
patients and monitor their effects.
3 Provide pharmaceutical care to patients Percentage of completion of tasks
based on medical evidence and enhance assigned to him according to work
the quality, effectiveness and efficiency of plans
therapeutic services
4 Implement safe systems for the use of drugs, Percentage of completion of tasks
monitor their side effects, and develop and assigned to him according to work
implement measures to enhance vigilance plans
and drug safety.
5 Providing pharmacological information Percentage of completion of tasks
to doctors, nurses and other health care assigned to him according to work
providers. plans
6 Cooperate effectively and positively with Percentage of completion of tasks
doctors, nurses and other health care assigned to him according to work
professionals to provide the best health plans
services to patients.
7 Participate in committees and medical Number of committees and
teams and prepare the necessary reports affiliated teams
8 Participate in the development of Percentage of completion of tasks
therapeutic evidence based on the best assigned to him according to work
international standards and practices plans
9 Participate in and prepare scientific research Number and importance of
related to pharmaceuticals research prepared
10 Any other tasks entrusted to him by the Rapid response and
head of the department and related to the implementation of assignments
area of specialization

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

42
 Qualifications and experience
Minimum Qualification Master in Clinical Pharmacy / Arab Board in Clinical Pharmacy
Or Bachelor of Pharmacy

Experiences Master without experience Arab Board in Clinical Pharmacy

+ 3 years’ experience in the same field Bachelor with pass the
resident clinical pharmacist program

Technical and behavioral competencies according to the levels

defined by the performance management system adopted in
the federal government
skills Behavioral Competencies -
Proficiency Level (PL4)
1 Work as one team. Familiarity with all policies, procedures and
regulations related to the field of work
2 Communication and communication Proficiency in dealing with resources and
skills planning use.
3 Focus on customer service Proficiency in Arabic and English.

4 Focus on results. International Computer Driving License(

ICDL)
5 Manage resources effectively Good knowledge of using the electronic
health record.
6 Accountability. Continuous self-development of the latest
scientific updates
7 Leading change Medical information assessment skills.

8 Empower and develop staff Scientific research skills

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

43
 Documentation of procedures

Preparation (Direct Date

Administrator)
Audit (direct Date
supervisor)
Accreditation (Undersecretary / Assistant Undersecretary) or similar

Signature

Director of Human Resources Department

Sealing and Accreditation

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

44
 Job Description Form
Details of Tasks
Job Title Specialist Clinical pharmacist

Job Code

Functional Category Job Evaluation and Presidency of the Council of

Characterization System: Ministers: Specialized and

technical and professional professional

Job Grade Second

Direct Chairman Head of Clinical Pharmacy Services Section

Administration Pharmacy Administration

Career Path Specialist professional

Functional family Health and safety

Sub-functional family Pharmacy

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

45
 The Overal Objective of the Job
Provide clinical pharmacy services to patients and interact effectively with doctors and nurses
to provide high quality therapeutic services.

Job Dimensions
Numbers of Direct Number of Units Number of Employees
Adminitrative Staff
of the Incumbent
Indirect

Financial Powers In accordance with the Manual of Government Financial

Procedures and the powers vested in the Federal Authority

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

46
 Key Responsibilities

Specialized Tasks Operational performance

indicators
1 Practicing the clinical pharmacy profession in Percentage of completion of
various therapeutic areas in accordance with the tasks assigned to him according
Ministry’s policies and internationally approved to work plans
standards for clinical pharmacy practices
2 Participate in meetings and rounds of medical Participation rate in meetings
teams about patients in the internal departments of and rounds of medical teams
the hospital and encourage the use of appropriate
treatments for patients and monitor their effects.
3 Provide pharmaceutical care to patients based Percentage of completion of
on medical evidence and enhance the quality, tasks assigned to him according
effectiveness and efficiency of therapeutic services to work plans
4 Supervise the implementation of safe systems for Percentage of completion of
the use of drugs, monitor their side effects, and tasks assigned to him according
develop and implement measures to enhance to work plans
vigilance and drug safety.
5 Providing pharmacological information to doctors, Percentage of completion of
nurses and other health care providers. tasks assigned to him according
to work plans
6 Training pharmacists and clinical pharmacy Percentage of completion of
students in clinical pharmacy practices tasks assigned to him according
to work plans
7 Cooperate effectively and positively with doctors, Percentage of completion of
nurses and other health care professionals to tasks assigned to him according
provide the best health services to patients. to work plans
8 Participate in committees and medical teams and Number of committees and
prepare the necessary reports affiliated teams
9 Supervise the development of therapeutic Percentage of completion of
evidence based on the best international standards tasks assigned to him according
and practices to work plans
10 Organization and preparation of scientific research Number and importance of
related to pharmaceuticals research prepared
11 Prepare duty rotation / shifts in the department Approved leave forms
and cover them consistently
12 Any other tasks entrusted to him by the head R a p i d r e s p o n s e a n d
of the department and related to the area of implementation of assignments
specialization

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

47
 Qualifications and experience
Minimum Qualification Master in Clinical Pharmacy / Arab Board in Clinical Pharmacy
PhD in Clinical Pharmacy

Experiences Master with 3 years’ experience

Arab Board in Clinical Pharmacy +6 years’ experience in the same
field
PhD in Clinical Pharmacy without experience

Technical and behavioral competencies according to the levels

defined by the performance management system adopted in
the federal government
skills Behavioral Competencies -
Proficiency Level (PL4)
1 Work as one team. Familiarity with all policies, procedures and
regulations related to the field of work
2 Communication and communication Proficiency in dealing with resources and
skills planning use.
3 Focus on customer service Proficiency in Arabic and English.

4 Focus on results. International Computer Driving License( ICDL)

5 Manage resources effectively Good knowledge of using the electronic

health record.
6 Accountability. Continuous self-development of the latest
scientific updates
7 Leading change Medical information assessment skills.

8 Empower and develop staff Scientific research skills

9 Strategic thinking Ability to lead, continuous supervision and

problem solving

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

48
 Documentation of procedures

Preparation (Direct Date

Administrator)
Audit (direct Date
supervisor)
Accreditation (Undersecretary / Assistant Undersecretary) or similar

Signature

Director of Human Resources Department

Sealing and Accreditation

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

49
 Job Description Form
Details of Tasks
Job Title Consultant Clinical pharmacist

Job Code

Functional Category Job Evaluation and Presidency of the Council of

Characterization System: Ministers: Specialized and

technical and professional professional

Job Grade First

Direct Chairman Head of Clinical Pharmacy Services Section

Administration Pharmacy Administration

Career Path Specialist professional

Functional family Health and safety

Sub-functional family Pharmacy

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

50
 The Overal Objective of the Job
Planning and leading the provision of clinical pharmacy services to patients and interacting
effectively with doctors and nurses to provide high quality therapeutic services

Job Dimensions
Numbers of Direct Number of Units Number of Employees
Adminitrative Staff
of the Incumbent
Indirect

Financial Powers In accordance with the Manual of Government Financial

Procedures and the powers vested in the Federal Authority

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

51
 Key Responsibilities

Specialized Tasks Operational performance

indicators
1 Practicing the clinical pharmacy profession in Percentage of completion of
various therapeutic areas in accordance with the tasks assigned to him according
Ministry’s policies and internationally approved to work plans
standards for clinical pharmacy practices
2 Continuous supervision of the teams and the Percentage of completion of
distribution of tasks to ensure the quality and tasks assigned to him according
effectiveness of performance to work plans
3 Organized and Participate in meetings and rounds Percentage of completion of
of medical teams about patients in the internal tasks assigned to him according
departments of the hospital and encourage the to work plans
use of appropriate treatments for patients and
monitor their effects
4 Plan and ensure the Provision of pharmaceutical Percentage of completion of
care to patients based on medical evidence and tasks assigned to him according
enhance the quality, effectiveness and efficiency to work plans
of therapeutic services
5 Manage the application of safe systems for the use Percentage of completion of
of medicines and monitor their side effects and tasks assigned to him according
develop and implement measures to enhance to work plans
vigilance and safety
6 Providing pharmacological information to Percentage of completion of
doctors, nurses and other health care providers tasks assigned to him according
to work plans
7 Supervise the Training of pharmacists and clinical Percentage of completion of
pharmacy students in clinical pharmacy practices tasks assigned to him according
to work plans
8 Cooperate effectively and positively with doctors, Percentage of completion of
nurses and other health care professionals to tasks assigned to him according
provide the best health services to patients. to work plans
9 Lead and Participate in committees and medical Number of committees and
teams affiliated teams
10 Technical approval of therapeutic evidence based Percentage of completion of
on the best international standards and practices tasks assigned to him according
to work plans
11 Supervision of scientific research related to Number and importance of
pharmaceuticals research prepared
12 Reporting the results of medication treatments, Number of errors
indicating errors and developing a follow-up The percentage of effectiveness
corrective plan of the corrective plan
Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

52
 13 Any other tasks entrusted to him by the head Rapid response and
of the department and related to the area of implementation of
specialization assignments

Qualifications and experience

Minimum Qualification PhD in Clinical Pharmacy
Master in Clinical Pharmacy

Experiences PhD in Clinical Pharmacy + 3 years’ experience in the same field

Master with 8 years’ experience

Technical and behavioral competencies according to the levels

defined by the performance management system adopted in
the federal government
skills Behavioral Competencies -
Proficiency Level (PL4)
1 Work as one team. Familiarity with all policies, procedures and
regulations related to the field of work
2 Communication and communication Proficiency in dealing with resources and
skills planning use.
3 Focus on customer service Proficiency in Arabic and English.
4 Focus on results. International Computer Driving License( ICDL)

5 Manage resources effectively Good knowledge of using the electronic health

record.
6 Accountability. Continuous self-development of the latest
scientific updates
7 Leading change Medical information assessment skills.

8 Empower and develop staff Scientific research skills

9 Strategic thinking Ability to lead, continuous supervision and

problem solving

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

53
 Documentation of procedures

Preparation (Direct Date

Administrator)
Audit (direct Date
supervisor)
Accreditation (Undersecretary / Assistant Undersecretary) or similar

Signature

Director of Human Resources Department

Sealing and Accreditation

Clinical Pharmacy Standards of Practice in Ministry of Health and Prevention facilities

54
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