Medication Therapy and Patient Care: Organization and Delivery of ServicesGuidelines285

ASHP Guidelines on a Standardized Method

for Pharmaceutical Care
Need for a Standardized Method
The purpose of this document is to provide pharmacists with a
standardized method for the provision of pharmaceutical care
in component settings of organized health systems. Since the
introduction of the pharmaceutical care concept1 and the development of the ASHP Statement on Pharmaceutical Care,2
considerable variation in pharmacists provision of pharmaceutical care has been noted. ASHP believes pharmacists need
a standardized method for providing pharmaceutical care.
This document describes a standardized method based
on functions that all pharmacists should perform for individual patients in organized health systems. The use of this
method would foster consistency in the provision of pharmaceutical care in all practice settings. It would support
continuity of care both within a practice setting (e.g., among
pharmacists on different work shifts caring for an acutely ill
inpatient) and when a patient moves among practice settings
(e.g., when an inpatient is discharged to home or ambulatory care). Further, a standardized method would establish
consistent documentation so that patient-specific and medication-related information could be shared from pharmacist
to pharmacist and among health professionals.
The need to identify the functions involved in pharmaceutical care and the critical skills necessary to provide
it was discussed at the San Antonio consensus conference
in 1993.3 Functions for the provision of pharmaceutical care
were identified by the practitioner task force of the Scope
of Pharmacy Practice Project.4 Those functions have been
defined in more detail in the pharmacotherapy series of the
ASHP Clinical Skills Program.59
These Guidelines are not specific to any practice setting. ASHP believes this standardized method can be used in
acute care (hospitals), ambulatory care, home care, long-term
care, and other practice settings. Functions can be tailored as
appropriate for a given practice setting. It is recognized that
the degree of standardization and tailoring appropriate for a
given work site will depend on the practice environment, the
organization of services (e.g., patient-focused or departmentfocused), working relationships with other health professionals, the health systems and patients financial arrangements,
and the health systems policies and procedures. ASHP believes the use of the systematic approaches encouraged by
these guidelines will assist pharmacists in implementing and
providing pharmaceutical care in their work sites.

Functions of Pharmaceutical Care

ASHP believes that a standardized method for the provision
of pharmaceutical care should include the following:

Collecting and organizing patient-specific information,

Determining the presence of medication-therapy
problems,
Summarizing patients health care needs,
Specifying pharmacotherapeutic goals,
Designing a pharmacotherapeutic regimen,

Designing a monitoring plan,

Developing a pharmacotherapeutic regimen and corresponding monitoring plan in collaboration with the
patient and other health professionals,
Initiating the pharmacotherapeutic regimen,
Monitoring the effects of the pharmacotherapeutic
regimen, and
Redesigning the pharmacotherapeutic regimen and
monitoring plan.

These major functions have been adapted, in part, from the

pharmacotherapy series of the ASHP Clinical Skills Program
and the final report of the ASHP Model for Pharmacy
Practice Residency Learning Demonstration Project.
Collecting and Organizing Pertinent Patient-Specific Infor
mation. Information should be collected and used as a patientspecific database to prevent, detect, and resolve the patients
medication-related problems and to make appropriate medication-therapy recommendations. The database should include the
following sections, each containing specific types of information to the extent that it is relevant to medication therapy:
Demographic
Name
Address
Date of birth
Sex
Religion and religious affiliation
Occupation
Administrative
Physicians and prescribers
Pharmacy
Room/bed numbers
Consent forms
Patient identification number
Medical
Weight and height
Acute and chronic medical problems
Current symptoms
Vital signs and other monitoring information
Allergies and intolerances
Past medical history
Laboratory information
Diagnostic and surgical procedures
Medication therapy
Prescribed medications
Nonprescription medications
Medications used prior to admission
Home remedies and other types of health products used
Medication regimen
Compliance with therapy
Medication allergies and intolerances
Concerns or questions about therapy

286Medication Therapy and Patient Care: Organization and Delivery of ServicesGuidelines

Assessment of understanding of therapy
Pertinent health beliefs
Behavioral/lifestyle
Diet
Exercise/recreation
Tobacco/alcohol/caffeine/other substance use or abuse
Sexual history
Personality type
Daily activities
Social/economic
Living arrangement
Ethnic background
Financial/insurance/health plan
Objective and subjective information should be obtained directly from patients (and family members, other caregivers,
and other health professionals as needed). A physical assessment should be performed as needed. In addition, information can be obtained by reviewing the patients health record
and other information sources.
Information in the patients health record should be understood, interpreted, and verified for accuracy before decisions are made about the patients medication therapy. With
access to the patients health record comes the professional
responsibility to safeguard the patients rights to privacy
and confidentiality. The Privacy Act of 1974,10 professional
practice policies,11,12 and policies and procedures of organized health systems provide guidance for the pharmacist in
judging the appropriate use of patient-specific information.
The patient (as well as family members, caregivers,
and other members of the health care team as needed) should
be interviewed. This is necessary for the pharmacist to establish a direct relationship with the patient, to understand the
patients needs and desired outcome, to obtain medicationrelated information, and to clarify and augment other available information. Pharmacists in many practice settings,
including ambulatory care, may need to perform physical
assessments to collect data for assessing and monitoring
medication therapy.
Information, including clinical laboratory test results,
gathered or developed by other members of the health care
team may not be in the patients health record. Therefore,
to ensure that the patient information is current and complete, other sources should be checked. Other sources may
include medication profiles from other pharmacies used by
the patient.
Although it is ideal to have a comprehensive database
for all patients, time and staffing limitations may necessitate choices regarding the quantity of information and the
number of patients to follow. Choices could be determined
by the health systems policies and procedures, by clinical
care plans, or by disease management criteria in the patients
third-party health plan.
Systems for recording patient-specific data will vary,
depending on pharmacists preferences and practice settings.
Electronic documentation is recommended. Some information may already be in the patients health record. Therefore,
when authorized, the additional information gathered by the
pharmacist should be recorded in the patients health record so that it can be shared with other health professionals.
Abstracted summaries and work sheets may also be useful.

Determining the Presence of Medication-Therapy Problems.

Conclusions should be drawn from the integration of
medication-, disease-, laboratory test-, and patient-specific information. The patients database should be assessed for any
of the following medication-therapy problems:

Medications with no medical indication,

Medical conditions for which there is no medication
prescribed,
Medications prescribed inappropriately for a particular
medical condition,
Inappropriate medication dose, dosage form, schedule,
route of administration, or method of administration,
Therapeutic duplication,
Prescribing of medications to which the patient is allergic,
Actual and potential adverse drug events,
Actual and potential clinically significant drugdrug,
drugdisease, drugnutrient, and druglaboratory test
interactions,
Interference with medical therapy by social or recreational drug use,
Failure to receive the full benefit of prescribed
medication therapy,
Problems arising from the financial impact of medication
therapy on the patient,
Lack of understanding of the medication therapy by
the patient, and
Failure of the patient to adhere to the medication regimen.

The relative importance of problems must be assessed on the

basis of specific characteristics of the patient or the medication. Checklists, work sheets, and other methods may be
used to determine and document the presence of medication-therapy problems. The method should be proactive and
should be used consistently from patient to patient.
Summarizing Patients Health Care Needs. The patients
overall needs and desired outcomes and other health professionals assessments, goals, and therapy plans should be
considered in determining and documenting the medicationrelated elements of care that are needed to improve or prevent deterioration of the patients health or well-being.
Specifying Pharmacotherapeutic Goals. Pharmacotherapeu
tic goals should reflect the integration of medication-,
disease-, laboratory test-, and patient-specific information,
as well as ethical and quality-of-life considerations. The
goals should be realistic and consistent with goals specified by the patient and other members of the patients health
care team. The therapy should be designed to achieve definite medication-related outcomes and improve the patients
quality of life.
Designing a Pharmacotherapeutic Regimen. The regimen
should meet the pharmacotherapeutic goals established with
the patient and reflect the integration of medication-, disease-, laboratory test-, and patient-specific information;
ethical and quality-of-life considerations; and pharmacoeconomic principles. It should comply with the health systems
medication-use policies, such as clinical care plans and disease management plans. The regimen should be designed for
optimal medication use within both the health systems and
the patients capabilities and financial resources.

Medication Therapy and Patient Care: Organization and Delivery of ServicesGuidelines287

Designing a Monitoring Plan for the Pharmacotherapeu
tic Regimen. The monitoring plan should effectively evaluate achievement of the patient-specific pharmacotherapeutic goals and detect real and potential adverse effects.
Measurable, observable parameters should be determined
for each goal. Endpoints should be established for assessing whether the goal has been achieved. The needs of the
patient, characteristics of the medication, needs of other
health care team members, and policies and procedures of
the health care setting will influence the monitoring plan.
Developing a Pharmacotherapeutic Regimen and Corre
sponding Monitoring Plan. The regimen and plan developed
in collaboration with the patient and other health professionals should be systematic and logical and should represent a
consensus among the patient, prescriber, and pharmacist. The
approach selected should be based on consideration of the
type of practice setting, its policies and procedures, practice
standards, and good professional relations with the prescriber
and patient. The regimen and monitoring plan should be documented in the patients health record to ensure that all members of the health care team have this information.
Initiating the Pharmacotherapeutic Regimen. Depending
on the regimen and plan, the pharmacist could, as appropriate, implement all or portions of the pharmacotherapeutic
regimen. Actions should comply with the health systems
policies and procedures (e.g., prescribing protocols) and
correspond to the regimen and plan. Orders for medications,
laboratory tests, and other interventions should be clear and
concise. All actions should be documented in the patients
health record.
Monitoring the Effects of the Pharmacotherapeutic Regi
men. Data collected according to the monitoring plan should
be sufficient, reliable, and valid so that judgments can be
made about the effects of the pharmacotherapeutic regimen.
Changes in patient status, condition, medication therapy, or
nonmedication therapy since the monitoring plan was developed should be considered. Missing or additional data
should be identified. Achievement of the desired endpoints
should be assessed for each parameter in the monitoring
plan. A judgment should be made about whether the pharmacotherapeutic goals were met. Before the pharmacotherapeutic regimen is adjusted, the cause for failure to achieve
any of the pharmacotherapeutic goals should be determined.
Redesigning the Pharmacotherapeutic Regimen and
Monitoring Plan. Decisions to change the regimen and plan
should be based on the patients outcome. When clinical circumstances permit, one aspect of the regimen at a time should
be changed and reassessed. Recommendations for pharmacotherapeutic changes should be documented in the same manner used to document the original recommendations.

Pharmacists Responsibility
An essential element of pharmaceutical care is that the pharmacist accepts responsibility for the patients pharmacotherapeutic outcomes. The same commitment that is applied to
designing the pharmacotherapeutic regimen and monitoring
plan for the patient should be applied to its implementation.

The provision of pharmaceutical care requires monitoring

the regimens effects, revising the regimen as the patients
condition changes, documenting the results, and assuming
responsibility for the pharmacotherapeutic effects.

References
1. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;
47:53343.
2. American Society of Hospital Pharmacists. ASHP
statement on pharmaceutical care. Am J Hosp Pharm.
1993; 50:17203.
3. Implementing pharmaceutical care. Proceedings of an
invitational conference conducted by the American
Society of Hospital Pharmacists and the ASHP
Research Foundation. Am J Hosp Pharm. 1993; 50:
1585656.
4. Summary of the final report of the Scope of Pharmacy
Practice Project. Am J Hosp Pharm. 1994; 51:2179
82.
5. Shepherd MF. Clinical skills program pharmacotherapy series module 1. Reviewing patient medical
charts. Bethesda, MD: American Society of Hospital
Pharmacists; 1992.
6. Mason N, Shimp LA. Clinical skills program pharmacotherapy series module 2. Building a pharmacists
patient data base. Bethesda, MD: American Society of
Hospital Pharmacists; 1993.
7. Mason N, Shimp LA. Clinical skills programmodule 3. Constructing a patients drug therapy problem
list. Bethesda, MD: American Society of Hospital
Pharmacists; 1993.
8. Jones WN, Campbell S. Clinical skills program pharmacotherapy series module 4. Designing and recommending a pharmacists care plan. Bethesda, MD:
American Society of Hospital Pharmacists; 1994.
9. Frye CB. Clinical skills program pharmacotherapy
series module 5. Monitoring the pharmacists care
plan. Bethesda, MD: American Society of Hospital
Pharmacists; 1994.
10. PL 93-579. 5 U.S.C.A. 552a (88 Stat. 1896).
11. ASHP guidelines for obtaining authorization for documenting pharmaceutical care in patient medical records. Am J Hosp Pharm. 1989; 46:3389.

12. Principles of practice for pharmaceutical care.
Washington, DC: American Pharmaceutical Association;
1995.

Approved by the ASHP Board of Directors, April 24, 1996.

Developed by the ASHP Council on Professional Affairs.
Copyright 1996, American Society of Health-System Pharmacists,
Inc. All rights reserved.
The bibliographic citation for this document is as follows: American
Society of Health-System Pharmacists. ASHP guidelines on a standardized method for pharmaceutical care. Am J Health-Syst Pharm.
1996; 53:17136.