A Method of Documenting Pharmaceutical Care Utilizing

Pharmaceutical Diagnosis

Stephen C. Hurley
College of Pharmacy, Idaho State University, Campus Box 8333, Pocatello ID 83209-8333

This paper proposes an outline for writing-up a patient case that can be used by experienced pharmacy
practitioners, or by students during case-study courses or clerkship training. When such written documen-
tation is placed in the patient’s primary medical record it not only communicates pharmacotherapeutic
evaluations and treatment recommendations but also serves as a record of pharmaceutical care. The well-
known SOAP outline, even in an expanded format, is not satisfactory for pharmacy because it uses clinical
information to characterize medical diagnoses rather than drug-related problems. The key element of the
write-up is pharmaceutical diagnoses. Pharmaceutical diagnoses define the nature of specific drug-related
problems. Each diagnosis serves as a foundation for desired outcomes, treatments, monitoring parameters,
and subjects for patient counseling and education.

INTRODUCTION
In 1995, four semesters of case study courses were intro-
duced into the curriculum of the College of Pharmacy at
Idaho State University. Faculty debated whether to use the
medical SOAP format or devise a new method of written
documentation based on the “pharmacists workup of drug
therapy(1).” The issue was never resolved. In the case study
course, students are required to learn three different ways to
write-up a patient case and clerkship faculty continue to use a
variety of methods. The problem of students being ex-
posed to differing methods of written documentation is not
unique to Idaho State University. Prosser et al. developed a
team-taught elective pharmacy course, for which a major

American Journal of Pharmaceutical Education Vol. 62, Summer 1998 119

goal was to develop professional writing skills(2). They
concluded that one reason students found it difficult to write
a “chart ready” note was that “each faculty member pre-
sented a different perspective on the optimal format.” They
also found that “writing skills, like clinical assessment skills,
are not easily acquired; it is a difficult and complex process.”
Subsequently, over the last two years, a considerable
amount of time has been spent conducting a literature
search, studying published methods of documentation, con-
ducting discussions with faculty, and field testing different
methods with both case study and clerkship students. The
following outline is a culmination of this effort. Although
not yet the standard for the College of Pharmacy, it has been
favorably received by both students and faculty.
To write-up a patient case, effective organization and a
well-developed flow of thought are very important. As in
any written composition, pharmacy documentation requires
a proper introduction, relevant information, clear reasoning
and a conclusion. Many acronyms have been coined that
suggest the proper steps to follow when writing-up a patient.
For example, the SOIP, later changed to the well-known
SOAP (subjective, objective, analysis, plan), was originally
designed by Dr. Lawrence L. Weed for medical doctors(3).
Other outlines include an expanded-SOAP (adds goals,
monitoring and education)(4,5), HOAP (replaces subjec-
tive and objective with history and observations)(6),
SOAPIER (used by nursing: adds implementation, evalua-
tion, revision)(7), DAR (used by nursing: data, action,
response)(7), FARM (findings, assessment, resolution,
monitoring)(8,9), PWDT (pharmacist’s workup of drug
therapy) (1), PMDRP (Pharmacist’s Management of Drug-
Related Problems)(10), or the American Society of Health-
System Pharmacist’s PCP (pharmacist’s care plan)(11).
These various approaches all contain important ele-
ments of documentation, but they all suffer from one or
more deficiencies. The original SOAP concentrates on de-
velopment of a medical diagnosis rather than drug-related
problems or pharmacotherapeutic assessment. The expanded
SOAP and FARM emphasize therapeutic problems, but
continue to be organized around medical diagnoses. The
PWDT is a lengthy “thought process that is meant to serve
as a guideline for the documentation of clinical pharmacy
activities and not simply a form to be completed on each
patient seen by a pharmacist(1).” It discusses, in a general
way, the issues that should be considered when evaluating a
patient data base and drug therapy, but does not describe
what the final write-up should actually look like. The PMDRP
is even more detailed than the PWDT. The authors state
that “The PMDRP can be overwhelming for pharmacists
because of its detail and length.”(10) Length is also a prob-
lem with the PCP. This method requires the pharmacist to
complete at least eight pages of forms.
During the initial training of undergraduate pharmacy
students, very detailed methods such as the PMDRP and the
PCP can help inexperienced students more fully internalize
aspects of the pharmaceutical care process. However, as
students progress and develop a basic knowledge of thera-
peutic principles, these methods become cumbersome and
inefficient. Eventually the student will internalize most of
the concepts and will not need explicit prompting.
In the Appendix, the same patient case is presented in
two formats. These two formats will be used to illustrate
differences in the way data can be presented and summa-
rized. One was organized with an expanded SOAP and the
120 American Journal of Pharmaceutical Education Vol. 62, Summer 1998
other with a new modular approach using pharmaceutical
diagnosis. Both versions contain about the same quantity of
clinical and therapeutic information. While the expanded
SOAP case is also utilized to demonstrate several other
common writing problems it should be pointed out that
these are not unique to the expanded SOAP format. They
should be avoided within any format of written documenta-
tion including the modular approach.
The expanded SOAP version of the case begins with the
chief complaint, history of present illness, past medical
history, social history, medication history, physical exami-
nation and laboratory measurements. Much of this informa-
tion is not necessary because it is already in the patient’s
medical record. Wouldn’t it be better to have the student
prepare a write-up just the way a clinical pharmacist would
do it under actual practice conditions? Students need to
learn how to recognize and utilize essential patient data
while filtering out the nonessential. The same reasoning
applies to general discussions of disease states or pharmaco-
therapeutics that are not applicable to the patient-specific
pharmaceutical diagnosis. These may be good learning as-
signments, but they should be done separately and not
included in the patient write-up.
After reviewing both versions of the case, consider the
following questions. If you had limited time to read a
pharmacist’s write-up, which format would be easier to
identify problems with the patient’s drug therapy, to know
exactly what changes in drug therapy were recommended,
to efficiently monitor the patient the next day, to counsel the
patient, or to prepare a bill for cognitive services?
NEW MODULAR FORMAT
The new format uses the following outline. In order to
remember the steps in this outline one might use the
following mnemonic “PH-MD-ROME.”
• Patient Introduction
• Health Problems
• Medications
• Pharmaceutical Diagnoses
• Recommended Orders
• Desired Outcomes
• Monitoring
• Patient Counseling and Education
Patient Introduction
The “Patient Introduction” module introduces the health
professional to the patient. It provides a thumbnail sketch of
the patient’s appearance and the situations that motivated
the patient to seek care. It also lays the groundwork for what
the pharmacist-patient relationship might involve. The fol-
lowing items would be included in this section; date of write-
up, patient’s name, age (or date of birth), race, height,
weight, admission date (applicable for inpatients), gender
and Chief Complaint (CC) or a description of the patient’s
present state. The patient’s last name may be used in the
remainder of the documentation. It is also common to refer
to “the patient,” or to use the patient’s initials.
Health Problems
Health problems may include a medical diagnosis, psy-
chiatric diagnosis, patient complaint, an abnormal labora-
tory test result, an abnormal observation (sign or symptom),
a social or financial situation, a psychological concern, or a
physical limitation/disability. Sometimes it is necessary for a
pharmacist to perform a physical or psychological examina-
tion or question the patient about his or her medical history.
Documentation of these activities should be recorded within
this module. If the patient has an allergy, this should be
noted as the last item. If the patient has no known allergies,
this should also be noted as confirmation that the pharma-
cist has sought a history of allergies.
Each health problem should be titled and placed in
order of clinical significance. Health problems should not be
numbered because they are not the emphasis of the write-
up, and it would lead to confusion when problems are
numbered in the pharmaceutical diagnosis module.
At this location in the write-up, information on the
patient’s medical history is integrated with recent observa-
tions in order to characterize the current health problem.
Besides presenting clinical findings, there is often a need to
interpret or explain the data. For example, in both versions
of the case, the patient’s chronic bronchitis is attributed to
smoking and the acute exacerbation is hypothesized to be
due to a viral infection and not a bacterial pneumonia. In the
modular format of the case, there is also an explanation that
the increased serum bicarbonate is due to renal compensa-
tion, and that the patient’s mood and symptoms are compat-
ible with diagnostic criteria for depression.
Students often scatter relevant health information
throughout their write-ups. By putting the information sup-
porting a particular health problem in only one location,
several pharmaceutical diagnoses can refer to the same
health/disease information without unnecessary duplica-
tion. For example, in the expanded SOAP format we find
fragmented information about the patient’s chronic bron-
chitis in the past medical history, social history, physical
examination, laboratory tests, and in the “S,” “O,” and “A”
of the SOAP under “Problem 1. Chronic Bronchitis Exacer-
bation.” While in the modular approach, all of this informa-
tion is organized under “Chronic Bronchitis in an Acute
Exacerbation.”
Drug treatment is not discussed in the health problems
module. Past and present drug treatment will be listed in the
medications module and discussed, if necessary, in the phar-
maceutical diagnoses module. At this point, a health profes-
sional needs to develop an in-depth understanding of both
the past course and present manifestations of the patient’s
medical/psychiatric problems without being distracted by a
discussion of pharmacotherapeutics.
Identification of information as subjective, objective, a
symptom or a sign has been overemphasized in the SOAP-
type of note(6). The patient’s complaints and point of view
are essential information, but they do not influence how the
write-up is organized in the modular approach. Rather than
concentrating and organizing information by type (i.e., sub-
jective versus objective) observations should be organized
in a way that clarifies the relevant pathophysiology and
supports therapeutic discussions found in the pharmaceuti-
cal diagnoses module.
Medications
The medication module is broken down into two sec-
tions; the present medication list and the past medication
list. The present medication list can be used as a screen for
drug interactions, duplication of therapy, polypharmacy,
allergies, and appropriate dosage.
In order to develop a past medication list a complete
drug history should be obtained. Drug histories are one of
American Journal of Pharmaceutical Education Vol. 62, Summer 1998
the more important tools for developing and assessing pos-
sible drug-related problems(12). The pharmacist should not
only determine the details of the past dosage regimens but
also investigate how well those regimens worked, the details
of any adverse events, and why the patient is no longer
taking the medications. The pharmacist should also assess
patient knowledge, discover practical impediments to opti-
mal drug utilization, and determine if there are attitudinal
barriers that might have an impact on compliance(13).
Pharmaceutical Diagnoses
Early in the development of clinical pharmacy practice,
medical diagnoses were used as the focus of thought pro-
cesses involved in establishing a systematic approach to
drug therapy(14). The pharmaceutical care movement has
stimulated pharmacy to reconsider and re-conceptualize the
type of problems that fall within the scope of pharmacy
practice.
Strand et al. defined a drug-related problem as “an
undesirable event, a patient experience that involves, or is
suspected to involve drug therapy, and that actually, or
potentially, interferes with a desired patient outcome.”(15)
The authors further state that “some relationship must exist
(or be suspected to exist) between the undesirable event and
drug therapy. The nature of the relationship will depend
upon the specific drug-related problem, but common rela-
tionships between an undesirable event and drug therapy
are: (i) the event is the result of drug therapy; and (ii) the
event requires drug therapy.”(15)
The original list of eight drug-related problems defined
by Strand et al. may be a good heuristic method to “provide
order in a pharmaceutical universe considered by many to
be chaotic,”(16) but it does not give many choices for titling
the numerous kinds of situations that could exist between
drug therapy and an undesirable event.
Pharmaceutical diagnosis is a concept discussed by
Culbertson et al.(17). In the past, pharmacists have avoided
the word “diagnosis” because diagnosis is supposed to be
only done by physicians. If medical diagnosis is defined by
Stedman’s Medical Dictionary(18) as the “determination of
the nature of a disease,” what would pharmacy diagnosis
be?
Culbertson et al. defined pharmaceutical diagnosis as “a
problem-centered, cognitive process used to identify pa-
tient-specific, drug-related problems,” and further proposed
23 pharmaceutical diagnostic categories organized under
seven general domains(17). They stated that the suggested
diagnostic definitions were preliminary and “it is conceiv-
able that different definitions or an entirely new structure
may eventually emerge.” Table I contains an expanded list
of 42 possible pharmaceutical diagnosis with brief defini-
tions. These were developed from a review of the literature
(8,11,17,19) and tested by pharmacy students in numerous
simulated and actual patient cases.
In the narrative under each pharmaceutical diagnosis,
the pharmacist should provide adequate evidence support-
ing the existence of a drug-related problem, and therapeutic
principles that will be used as a basis for solving the problem.
For example, the patient in the case exhibits a maculopapu-
lar rash. Both case formats conclude that the timing of the
rash is compatible with the initiation of doxycycline. Is this
enough evidence to convince a reader that the rash was due to
doxycycline rather than warfarin, terbutaline or acetami-
nophen? If the writer had done a comprehensive assessment
121
Table I. Suggested pharmaceutical diagnoses.
Diagnosis
Related to Medical Diagnosis
Incomplete medical evaluation
Uncharacterized signs and symptoms
Related to the Prescription
Unclear or incomplete prescription
Suboptimal dosage form
Not receiving
Suboptimal dosage schedule
Subtherapeutic dose
Excessive dose
Excessive duration of use
Insufficient duration of use
Unidentified medication
Related to Evaluation of Drug Therapy
Untreated health problem
Need for prophylactic/preventative/
continuation/or maintenance
therapy
Suboptimal response
Questionable indication
Uncertain indication
Lacking justification
Questionable justification
Duplication of action
Lacking pharmacokinetic evaluation
Related to Adverse Effects of Drug Therapy
Adverse drug reaction
Absolute contra-indication
Relative contra-indication
Potential adverse drug/diet interaction The patient is at risk for an ADR the etiology of which would involve diet.
Potential adverse drug/drug interaction The patient is at risk for an ADR the etiology of which would involve an interaction
Potential drug/laboratory interaction
Related to Monitoring
Need for prophylactic monitoring
Inadequate monitoring of clinical data Need for systematic observations of subjective and/or objective clinical data to either
Excessive monitoring of clinical data
Inadequate therapeutic drug monitoring Systematic measurements of drug concentrations are needed for pharmacokinetic
122 American Journal of Pharmaceutical Education Vol. 62, Summer 1998
Definition
Physician has not completed a diagnostic workup needed for evaluation of drug
therapy.
Physician has not yet initiated a diagnostic workup needed for evaluation of drug
therapy.
A prescription order is lacking essential information or needs clarification.
There is a better dosage form or route i.e. parenteral, sustained release, liquids,
tablets, capsules, flavor, topical, suppositories etc.
A drug has been recommended or prescribed but not dispensed, administered or
refilled. Apply the poor compliance diagnosis when the patient is responsible for
not taking the medication.
Dosage schedule is either inconvenient or does not result in optimal pharmacokinetic
or pharmacodynamic profile.
Considering all patient-specific factors, the dosage is below that which normally will
produce or sustain a satisfactory outcome.
Considering all patient-specific factors, the prescribed dosage is higher than usually
needed to produce satisfactory outcome and/or may place the patient at risk for
an ADR
Drug is no longer needed.
Drug was discontinued before desired outcome could be attained.
The patient does not know the name of a medication nor can it be easily identified by
physical appearance.
An indication exists for drug or non-drug therapy. This diagnosis usually applies to a
newly characterized health problem. However, it could apply to an older health
problem if no other diagnosis is more descriptive of why the health problem is
untreated.
“Preventative” and “prophylactic” are often interchangeable, continuation
suppresses relapse while disease is in remission, maintenance reduces
recurrences after patient recovers.
Clinical evidence argues that the present drug treatment has been given an adequate
trial in regard to dose and duration but does not meet desired outcomes related
to efficacy.
No apparent health problem for which the drug might be used.
Several health problems exist for which the drug might be used.
An indication exists, but the literature strongly argues that the drug is either not very
effective and/or has a high risk of adverse effects compared to other available
alternatives.
An indication exists, but the literature suggests that other alternatives are more effective
and/or safer
Two drugs are being given. One drug is sufficient, the other is probably not needed.
Pharmacokinetic parameters need to be estimated and used to evaluate dosage and/
or drug levels.
An adverse drug reaction (ADR) is possibly, probably or definitely occurring. The
undesirable event is caused by a drug,, unintended, noxious, and results in an
adverse outcome.
The patient is at high risk for an ADR the etiology of which would involve a drug/
disease interaction
The patient is at moderate risk for an ADR the etiology of which would involve a
drug/disease interaction
between drugs.
The patient is at risk for an ADR, the adverse event would be an altered laboratory
measurement.
Patient is at risk for acquiring a health problem that would need drug therapy.
characterize a health problem, evaluate drug therapy or determine if desired
outcomes are being met.
Some clinical measurements related to drug therapy are not necessary, resulting in
increased cost, and/or inconvenience, and/or risk to the patient
calculations or to assure that drug levels remain within the established therapeu-
tic range.
Table I. Suggested pharmaceutical diagnoses (con’t)
Diagnosis Definition
Excessive therapeutic drug monitoring Some drug concentration measurements are not necessary, resulting in increased
cost, and/or inconvenience, and/or risk to the patient
Unfinished trial of drug therapy More time needs to elapse before an evaluation of new, modified or discontinued
drug therapy can be completed.
Related to Patient Factors
Poor compliance Usually refers to taking less than prescribed or not adhering to other directions for
proper use.
Problematic substance use Patient takes either a prescription drug or an illicit drug for the purpose of intoxica-
tion.
Detrimental physical dependence Dose reduction or drug discontinuation would lead to withdrawal symptoms.
Intentional overdose Intentional self-administration of a potentially toxic dose.
Excessive utilization Patient takes more than prescribed, or more than recommended for an OTC product,
in an effort to increase therapeutic effect, but not for the purpose of intoxica
tion. The resulting dose is excessive and may place the patient at risk for an
ADR.
Improper storage Refers to temperature, type of container, moisture, exposure to light, contamination,
etc..
Related to Patient Counseling
Deficient counseling There is a specific topic that needs to be included during patient counseling
Poor technique using a device Patient Counseling needs to include a demonstration of proper technique and
assurance that the patient will use the device properly in the future.
Related to Costs
Poor cost-effectiveness The present drug is more costly than another equally justified alternative. This
diagnosis could refer to simply selecting another brand or generic product, or
may refer to substitution with a different chemical entity.
Financial burden Cost of a drug or the drug regimen may result in a serious financial barrier to the
patient.
of the potential adverse drug reaction it would have re- case documentation states that “the use of antibiotics in this
quired evaluation of at least four pieces of evidence, only situation is controversial.” What does controversial mean?
one of which is the temporal relationship between drug use Could the prescriber feel comfortable beginning ampicillin
and an adverse event(20). Therefore the present case mate- when the risks and benefits are unknown. This would be a
rial might be adequate for communication between health good location for the following abstract.
professionals that trust each other’s judgment but might not
be satisfactory when the intended reader has not developed A two-year, double blind, crossover study of 173
confidence in the pharmacist’s capabilities. patients with stable chronic obstructive pulmonary
Establishment of a pharmaceutical diagnosis narrows disease compared antibiotics (TMP-SMX, or
the options for therapy. However, there are always several amoxicillin, or doxycycline) with placebo during an
ways to solve a problem. If a drug is to be initiated, modified, acute exacerbation. Although resolution of an ex-
or discontinued, the benefits and risks should be discussed. acerbation within 21 days occurred in 68 percent of
Therapeutic principles should be explained in enough detail the antibiotic treated patients, versus 55 percent of
to educate or convince other health professionals that the the placebo treated patients (P<0.01), most of the
rationale is appropriate. A limited discussion and compari- effect was accounted for by very symptomatic pa-
son of alternate solutions may help clarify desirable options. tients(21).
However, extensive information about alternate drug The methodology section within a current primary ar-
therapy need only be included if there is a chance that a drug ticle can also demonstrate how experts monitor drug therapy
of first choice may not meet expectations or has a potential and decide when a favorable outcome has been achieved.
to produce significant adverse effects. This type of information is often difficult to extract from
Referencing primary literature is an effective way to product information, textbooks and review articles.
convince health professionals that your assessments or rec-
ommendations are substantiated by current scientific evi- Recommended Orders
dence. Primary references report the results of original This and the next three modules (outcomes, monitoring
research, and support an analysis, an evaluation, or an and education) are designed to resolve drug-related prob-
argument in areas that may be controversial, or where lems. Each suggestion within these modules should be pre-
uncertainty exists. References should not refer to well- ceded by a number corresponding to a pharmaceutical
known information that can be found in common medical or diagnosis. They are organized somewhat like check off lists.
pharmacy textbooks or review articles. A primary journal Further data analysis, discussions or synthesis of plans would
article can be summarized in two sentences. The first sen- only dilute the impact of proposed actions. Therefore, all
tence describes the study duration, type of study, the num- narrative should be completed within the preceding health
ber of final patients, type of patients, and the key indepen- problems module or pharmaceutical diagnoses module.
dent variable. The second sentence provides the key depen- Recommendations usually deal with medications, but
dent variable, result, and statistical significance. may involve non-drug therapies or another service. Non-
An example is antibiotic use for chronic bronchitis. The drug therapy recommendations might include sending for

American Journal of Pharmaceutical Education Vol. 62, Summer 1998 123

old medical records, contacting a health care provider or
third party payer, providing drug information to a health
care provider, facilitating referral to health and social ser-
vice agencies, developing a compliance aid, etc. Recommen-
dations concerning medications should be written as con-
cisely as possible, using common prescription abbreviations,
and list the specific drug, dosage form, dose, route, dosing
schedule and length of therapy.
In the expanded SOAP case, under the plan for chronic
bronchitis exacerbation, a dose range was suggested for
methylprednisolone. A specific dose, rather than a range is
more appropriate. It is also inappropriate to represent the
dose using relative units based on weight such as “mg/kg.” A
pharmacist should have the expertise to determine the exact
dose based on patient specific considerations such as seri-
ousness of the health problem and pharmacokinetic calcula-
tions.
Desired Outcomes
Desired outcomes (also known as objectives or end-
points) should be specific. They should state exactly what
changes, or lack of changes, in the monitoring parameters
would reasonably document the attainment of adequate
therapeutic results, and assure that the patient was not
experiencing any significant adverse drug reactions. Whereas
monitoring parameters are often repeated measurements,
an outcome is a criterion that is applied to one or more of
these measurements following a specific time interval. If the
outcome is not met it should be reevaluated and a new
outcome should be set. Outcomes are similar to mile mark-
ers along a highway. They tell whether the patient has
progressed to a certain desirable point or not.
The synthesis of patient specific outcomes can only be
accomplished after the pharmacist has a clear understand-
ing of the patient’s health problems and pharmaceutical
diagnoses. In the context of a pharmacy write-up, analysis
should be completed in the health problems and pharma-
ceutical diagnoses modules. If outcomes are presented too
early in the write-up they often turn out to be general health
or therapeutic goals and possibly unrealistic for specific
patients. For example, in the expanded SOAP version of the
case, a goal to “decrease morbidity and mortality associated
with chronic bronchitis” is not patient specific. Even refin-
ing the goal to “improve respiratory function and prevent a
future exacerbation of chronic bronchitis,” or to “optimize
bronchodilator therapy” is not much better. In the modular
version of the case, the desired outcomes for pharmaceutical
diagnosis #1 “Suboptimal Response to Bronchodilators”
explicitly state the values we want to achieve for: (i) FEV1;
(ii) respiratory rate; and (iii) arterial blood gases.
Monitoring
Monitoring parameters are those laboratory tests, clini-
cal measurements, and observations that are to be prospec-
tively followed in order to provide feedback on the status of
the patient’s health problems and pharmaceutical diagnosis.
Each parameter should include the time when it will be
obtained and by which health professional, if that is not
implicitly clear. The most important monitoring parameters
are those that correspond to the outcomes above. Each
monitoring parameter (or a few related parameters) should
be written on a separate line so that the result can be used as a
check off list. In the expanded SOAP, notice how the
monitoring parameters were presented for “Problem 1.
124 American Journal of Pharmaceutical Education Vol. 62, Summer 1998
Chronic Bronchitis Exacerbation.” They are all mixed up in
one sentence. Now look at the modular write-up. As you can
see, they are basically the same parameters, but some are
done daily, and some only once, at a specific time. The
parameter to be done by the laboratory is clearly indicated.
Terminology should be avoided that is general and may
not be uniformly interpreted by different readers. For ex-
ample, in the expanded SOAP format under monitoring for
depression, how should we measure “quality of life?” There
are published rating scales for quality of life. Are we going
to use one of those, or are we just going to ask the patient
about his quality of life? Under monitoring for side effects,
what is meant by “anticholinergic side effects?” Anticholin-
ergic side effects cover a broad range of symptoms. It would
be better to select and specifically monitor a few of the more
common anticholinergic side effects.
In the ambulatory setting, a patient may not return to
see the pharmacists for weeks or months. Between visits, the
patient must be counseled to report if a health problem does
not resolve, or if side effects occur. Although this type of
advice appears to be monitoring, it should be placed in the
next module “patient counseling and education.”
Patient Counseling and Education
This module lists specific, unique, and important infor-
mation, advice, training, and encouragement that the phar-
macist will provide to the patient. The purpose of counseling
is to help the patient take appropriate responsibility for the
proper management of his or her illness and for recognizing
and dealing with side effects of medications. If there is a
diagnosis of “poor compliance,” or a diagnosis related to
patient counseling, then the patient counseling module must
contain directions for correcting the problems.
A pharmacist does not have to prepare a written list of
all the subjects that are mandated in The Omnibus Budget
Reconciliation Act of 1990(22). However, the pharmacist
will be responsible for discussing these items with the pa-
tient. For a general review of patient counseling, the reader
is referred to the ASHP Guidelines on Pharmacist-Con-
ducted Patient Education and Counseling(23).
The wording of this module should indicate if patient
counseling has already been completed. If it has been com-
pleted, the write-up should document the patient’s accep-
tance and apparent understanding of the information. If
patient counseling is performed at some later time the
pharmacist should return to the patient’s record and write a
progress note confirming that the counseling was done, the
date completed, and the pharmacist’s initials.
SUMMARY
A pharmacist must know what to write before sitting down
and completing the document. This requires a thoughtful
assessment of all available information in patient medical
records, a discussion with the physician and other caregivers,
and an interview with the patient. As the pharmacy student
or pharmacist becomes proficient, fewer notes and rough
drafts will be needed and the content and ideas will be easier
to keep organized in his or her head. Although the modular
approach does not necessarily represent a thought-process
for problem solving, the concepts embodied in the method
will hopefully result in a written product that more effec-
tively communicates the results of such cognitive processes.
Very little in a write-up can be simply copied down from the
chart or other sources of patient information. The truly
valuable information in a write-up is the ideas generated by
the pharmacist.
In case study courses and clinical clerkships, a compre-
hensive write-up may be many pages long. In the real world
of pharmacy practice, a complete patient evaluation may be
limited to one or two pages, and progress notes condensed
to just a few paragraphs. Progress notes may not use all the
modules; however, they should still include at least one
pharmaceutical diagnosis. In a progress note the pharmacist
may document changes in health problems, update pharma-
ceutical diagnoses, recommend new orders, document
whether outcomes have been attained, report the results of
monitoring, or record the success of patient counseling.
The modular write-up produces a document with an
organized source of patient data, clear problem identifica-
tion, and an explicit set of actions taken to resolve problems.
Summary reports based on a number of write-ups could be
used to evaluate type of care provided, patient outcomes,
work load, costs and quality of care. Reimbursement or
funding for non-dispensing, clinical service continues to be
an important goal for pharmacy. Just as the medical progress
note and medical diagnosis are used for physician reim-
bursement, pharmacy documentation and pharmaceutical
diagnosis could serve the same function for pharmacists.
Acknowledgment. The author would like to thank Dr. Joy
Matsuyama for submitting material used in the patient case.
Am. J. Pharm. Educ., 62,119-127(1998); received 12/4/97, accepted 3/27/98.
References
(1) Strand, L.M., Cipolle, R.J. and Morley, P.C., “Documenting the
clinical pharmacists activities: Back to basics,” Drug. Intell. Clin.
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APPENDIX: PATIENT CASE WRITTEN IN TWO
DIFFERENT FORMATS
1. MODULAR FORMAT
PATIENT INTRODUCTION
Date 2/24/97
K.H. is a 52-year-old, 80 kg, 5’7” male who comes to the clinic
today with continued complaints of shortness of breath and
increased sputum production.
He reports that a rash began yesterday.
He also complains of feeling depressed, lacking energy, wak-
ing up early in the morning and not being able to go back to
sleep, a decreased appetite, and a general lack of interest in
everything, including his job and his family for the last 6 weeks.
Although he has several medical problems, he has been doing
well prior to this episode.
HEALTH PROBLEMS
Chronic Bronchitis in an Acute Exacerbation
SOB has been increasing over the last two years. The present
respiratory rate is increased to 32. K.H. continues to smoke 1
pack per day. He has 50 pack-year history. Smoking is the most
likely etiology of the chronic bronchitis. Numerous rales,
rhonchi, and wheezes are heard on auscultation. Hct and Hgb
are in the upper normal range ruling out anemia as a cause for
the SOB. Their elevation is probably secondary to hypoxia.
Arterial blood gases indicate poor gas exchange, Pco2 is
increased to 49 mm/Hg (normal 35-45), and Po2 is decreased to
55 mm/Hg (normal 80-100). An increased bicarbonate of 28
mEq/L (normal 20-26) shows compensation by the kidney
resulting in a pH of 7.37, which is low-normal.
WBC and differential are normal, temperature is normal,
and chest x-ray is clear ruling out pneumonia. Gram stain of
sputum sample was unsuitable due to numerous squamous
epithelial cells A viral upper respiratory tract infection may be
the cause of the acute exacerbation.
A pre-bronchodilator FEV1 = 2000 mL (50% of VC)
indicates obstruction. However a post-bronchodilator FEV1
= 2600 mL (65% of VC) shows that this obstruction has a
reversible component.
Rash
K.H. does not complain of itching. He has a maculopapular
rash on trunk and thighs. His eosinophiles are in the normal
range.
Depression
The five symptoms mentioned under patient introduction and
125
 their duration of over six weeks are consistent with a major
depressive episode. However his breathing problem may be
contributing to the mood disorder. The patient does not
appear to be suicidal at this point.
Deep Vein Thrombosis
Patient injured his right leg in a fall seven months ago. Deep
vein thrombosis in the calf developed a week later. The
measurements of INR have shown wide swings over the last
seven months. Presently the INR has stabilized around 3.0 for
the last two months.
No Known Allergies
MEDICATIONS
Present Medication List
Theodur 600 mg bid for 2 years
Terbutaline inhaler 4 puffs qid and PM for 2 years
Vibramycin 100 mg qd for bronchitis x 10 days
Warfarin 3 mg qd, started seven months ago
Acetaminophen prn HA
Past Medication List
Unknown
PHARMACEUTICAL DIAGNOSIS
1. Suboptimal Response to Bronchodilators
K.H. has a symptomatic exacerbation of his chronic bronchitis
that requires further treatment. The reversible airway ob-
struction would probably be amenable to additional
bronchodilators. A theophylline level of 12 mg/L is within the
therapeutic range and pharmacokinetically consistent with
his dosage. The use of antibiotics in this situation is controver-
sial, although recent evidence suggests a benefit.
2. Adverse Drug Reaction to Doxycycline
K.H. has developed a rash probably due to the doxycycline
started 9 days ago. The usual drug rash is maculopapular and
commonly occurs after 7-10 days of therapy. Avoid antihista-
mines unless K.H. is itching, because they are sedating and
have anticholinergic effects.
3. Untreated Depression
K.H. has had his current complaints for more than a month.
While he does not appear to be suicidal at this point, he needs
treatment. Fluoxetine is as effective, has less side effects, and,
when all costs are taken into account, is no more expensive to
use than older tricyclic antidepressants such as imipramine
and desipramine.
4. Excessive Duration of Warfarin Prophylaxis
Since the patient has only had one occurrence of deep vein
thrombosis, warfarin therapy is usually discontinued after six
months of prophylactic treatment
RECOMMENDED ORDERS
1. Methylprednisolone 45 mg iv stat and continue q 6 h for 72
hours.
Aerosolized metaproterenol 4 puffs stat and 1 puff q 5 minutes
until relief or side effects, then two puffs every 4 hours while
awake.
Continue oral theophylline, 600 mg bid.
Oxygen 2 liters/minute via nasal prongs.
Ampicillin 500 mg po qid for seven days.
2. Discontinue Vibramycin.
Label K.H. allergic to doxyclycline.
Aveeno baths for a soothing effect as needed.
3. Fluoxetine 20 mg qd in AM or at noon. Continue therapy for
6 months.
4. Discontinue warfarin
DESIRED OUTCOMES
1. FEV1 greater than 2000 mL within two days
Respiratory rate below 20, within two days
ABG should all be within normal ranges within four days
2. Resolution of rash within 5 days
126 American Journal of Pharmaceutical Education Vol. 62, Summer 1998
3 Patient’s appetite and sleep moderately improved within one
week and mood moderately improved within 4 weeks, with no
report of suicidal ideation or side effects listed in monitoring
below.
MONITORING
While hospitalized
1. Daily, patient’s report of SOB and sputum production
Daily, respiratory rate and FEV1
Daily, chest auscultation
In 4 days, laboratory to measure arterial blood gases
2. Daily, examine rash
3. Daily, dietary to record percent of each meal eaten,
Daily, nursing to record hours of sleep the night before
Daily, patient report of mood, interest in life, and suicidal
thoughts
1.&3. Daily, patient report of adverse effects: headaches, anxiety,
insomnia, nausea, dry mouth, constipation, drowsiness, or
dizziness
PATIENT COUNSELING AND EDUCATION
1. Assess K.H.’s ability to use his inhaler correctly and correct
any problems. Provide a spacer if necessary. Explain the likely
side effects of bronchodilators: nausea, palpitations, anxiety
or insomnia. K.H. should discontinue smoking; refer him to a
smoking cessation clinic.
2. Educate patient that he has an allergy to doxycycline and
possibly other tetracyclines.
3. Advise patient to take fluoxetine in the morning or at noon to
help prevent insomnia. Antacids may help with nausea. This
drug may cause drowsiness or dizziness, so caution is advised
when driving or operating machinery. It will take several
weeks for this drug to work or side effects to develop.
2. EXPANDED SOAP FORMAT
CHIEF COMPLAINT
K.H. is a 52-year-old man who comes to the clinic today with
complaints of shortness of breath and increased sputum pro-
duction.
HISTORY OF PRESENT ILLNESS
He reports that a rash began yesterday.
He also complains of feeling depressed, lacking energy, wak-
ing up early in the morning and not being able to go back to
sleep, a decreased appetite, and a general lack of interest in
everything, including his job and his family for the last 6 weeks.
Although he has several medical problems, he has been doing
well prior to this episode.
PAST MEDICAL HISTORY
Chronic bronchitis secondary to smoking. Increasing SOB
over last two years.
Patient injured his right leg in a fall seven months ago. Deep
vein thrombosis in the calf developed a week later.
SOCIAL HISTORY
K.H. has a stable and happy marriage; he has two sons in
college, both doing well. K.H. continues to smoke 1 pack per
day; he has 50 pack-year history. K.H. tried marijuana once
with his son but did not like it.
MEDICATION HISTORY
Theodur 600 mg bid for 2 years
Terbutaline inhaler 4 puffs qid and PM for 2 years
Vibramycin 100 mg qd for bronchitis x 10 days
Warfarin 3 mg qd, started 7 months ago
Acetaminophen prn headache
ALLERGIES cultation, theophylline level, nausea, vomiting, pulse, blood
None known glucose, serum potassium, blood pressure, and tremor.
The goal is to decrease morbidity and mortality associated
PHYSICAL EXAMINATION with chronic bronchitis.
GEN: Middle aged man, in severe distress Assess K.H.’s ability to use his inhaler correctly and correct
VS: BP 120/80, HR 100 reg, T 37.6, RR 32, Wt 80 kg, any problems. Provide a spacer if necessary. Explain the likely
Ht 5’7” side effects of theophylline, steroids, and ampicillin. K.H.
HEENT: Normal should discontinue smoking; refer him to a smoking cessation
COR: Normal SI and S2; no S3, S4 or murmurs clinic.
CHEST: Numerous rales, rhonchi, and wheezes
ABD: No organomegaly PROBLEM 2. DRUG ALLERGY
GU: WNL S: K.H. complains of a rash that began yesterday, but does not
RECT: WN complain of itching.
EXT: NL DTRs, maculopapular rash on trunk and O: K.H. has maculopapular rash on trunk and thighs, his
Thighs eosinophiles are 1.2.
NEURO: Oriented x 3, WNL A: K.H. has developed a rash due to the doxycycline started 9
days ago. The usual drug rash is maculopapular and com-
RESULTS OF LABORATORY TESTS monly occurs after 7-10 days of therapy. Avoid antihistamines
Na 140 Hct 55 Alb 4 K 4.0 unless K.H. is itching, because they are sedating and have
Hgb 17.5 TBili .8 Cl 101 WBC 8.1 anticholinergic effects.
Glu 95 Uric acid 7.4 HCO3 28 Pits 305k P: Discontinue Vibramycin. Aveeno baths for a soothing effect
Ca 8.8 BUN 37 Cr 1.2 P04 2.6 may be needed. Label K.H. allergic to doxycycline.
AST 40 ALT 35 Mg 2.0 PT 25(INR=3) Monitor for resolution of the rash.
WBC differential: Neutrophils 4.8, bands 0, lymphs 3.0, monos Educate patient that he has an allergy to doxycycline and
.5, eos .12 possibly other tetracyclines.
ABGs: pH 7.37, Po2 55, PCO2 49
PFTs: pre-bronchodilator FEV1 = 2000 mL (50% of FVC), PROBLEM 3. DEPRESSION
post-bronchodilator FEV1 = 2600 mL (65% of FVC) S: K.H. complains of feeling depressed, lacking energy, waking
Gram stain of sputum sample was unsuitable due to numerous up early in the morning and not being able to go back to sleep,
squamous epithelial cells a decreased appetite, and a general lack of interest in every-
Urinalysis: WNL thing, including his job and his family for the last 6 weeks.
Chest x-ray: Clear, no signs of pneumonia O: None.
A: K.H. has had his current complaints for more than a month.
PHARMACY-RELATED PROBLEM LIST While he does not appear to be suicidal at this point, he needs
1. Chronic bronchitis in an acute exacerbation treatment. Fluoxetine is as effective, has less side effects, and,
2. Drug allergy when all costs are taken into account, is no more expensive to
3. Depression use than older tricyclic antidepressants such as imipramine
4. Deep Vein Thrombosis and desipramine.
P: Begin fluoxetine 20 mg qd in AM or at noon. Continue
PROBLEM 1. CHRONIC BRONCHITIS EXACERBATION therapy for 6 months.
S: K.H. complains of SOB and increased sputum production. Monitor changes in appetite, sleep pattern, interest in life,
O: K.H. has a decreased FEV1, rales, rhonchi, wheezes, an mood, quality of life, and suicidal thoughts. Physiologic signs
increased respiratory rate, pulse, Hct and Hgb, and arterial and symptoms should improve in 1 week, while mood will take
blood gases that show an increased PCO2 and a decreased 2-4 weeks to respond. Also monitor for headaches, anxiety,
oxygen. K.H. has a 50 pack-year smoking history. insomnia, nausea, somnolence, dizziness or anticholinergic
A: K.H. has a symptomatic exacerbation of his chronic bronchitis side effects.
that requires treatment. Smoking is the most likely etiology of Advise patient to take fluoxetine in the morning or at noon
the chronic bronchitis, while a viral upper respiratory tract to help prevent insomnia. Antacids may help with nausea.
infection is probably the cause of the acute exacerbation since This drug may cause drowsiness or dizziness, so caution is
K.H. shows no signs of systemic bacterial infection. He has a advised when driving or operating machinery. It will take
normal WBC, he is afebrile, and his chest x-ray is clear. The several weeks for this drug to work or side effects to develop.
use of antibiotics in this situation is controversial, although
recent evidence suggests a benefit. Pre-bronchodilator and PROBLEM 4. DEEP VEIN THROMBOSIS
post-bronchodilator FEV1 show reversible airway obstruc- S: No complaints
tion. The theophylline level is within the therapeutic range O: The measurements of INR have shown wide swings over the
and there is no need to increase the dose. last seven months. Presently the INR has stabilized around 3.0
P: Give methylprednisolone 40-125 mg iv stat and continue q6h for the last two months.
for 72 hours. Give aerosolized metaproterenol 4 puffs stat and A: Since the patient had only one occurrence of deep vein
1 puff q 5 minutes until relief or appearance of side effects. thrombosis, warfarin therapy is usually discontinued after six
Continue oral theophylline. Begin oxygen 2 liters/minute via months of prophylactic treatment.
nasal prongs. Begin ampicillin 500 mg po qid. P: Discontinue warfarin
Monitor SOB, sputum production, FEV1, ABGs, chest aus

American Journal of Pharmaceutical Education Vol. 62, Summer 1998 127