A method of documenting pharmaceutical care utilizing pharmaceutical diagnosis

American Journal of Pharmaceutical Education, Summer 1998 by Hurley, Stephen C

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 documentation 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 wellknown 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 introduced 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 exposed 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 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 presented 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, conducting 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 subjective and objective with history and observations)(6), SOAPIER (used by nursing: adds implementation, evaluation, 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 HealthSystem Pharmacist's PCP (pharmacist's care plan)(11).

These various approaches all contain important elements of documentation, but they all suffer from one or more deficiencies. The original SOAP concentrates on development 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 problem 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 therapeutic 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 summarized. One was organized with an expanded SOAP and the 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 documentation including the modular approach.