11.1 The Patient Care Process: Assessment, Care Plans, and Follow-Up
Key Takeaways
- The patient care process is a cyclical five-step framework — collect, assess, plan, implement, and monitor and follow up — and the cycle is incomplete without a scheduled follow-up date.
- Every drug therapy problem falls into one of four categories: indication, effectiveness, safety, or adherence.
- A best possible medication history is built from at least two independent sources, one of which is the patient or caregiver.
- Therapeutic goals must be specific, measurable, and time-bound, naming the parameter, the target, and the date it will be reassessed.
- SOAP documentation records subjective and objective findings, the pharmacist's assessment, and the plan, and it is the legal record of the clinical decision.
11.1 The Patient Care Process: Assessment, Care Plans, and Follow-Up
Exam Focus: The PEBC blueprint names "patient care process (assessment/intervention/monitoring/follow up/documentation)" as its own subcategory of Pharmacy Practice. Many Evaluating Examination items are really process questions in clinical clothing: the correct answer is the step the pharmacist has not yet completed.
The Five-Step Cycle
Canadian pharmacy practice uses a cyclical patient care process. It is a cycle, not a checklist, because the outcome of one round feeds the next.
| Step | What it involves |
|---|---|
| Collect | Demographics, medical and medication history, allergies, laboratory data, social and cultural context, goals and preferences |
| Assess | Interpret the information, evaluate each therapy for indication, effectiveness, safety, and adherence, and identify drug therapy problems |
| Plan | Set measurable goals, select therapy with the patient, define monitoring parameters, and set a follow-up date |
| Implement | Initiate, modify, or discontinue therapy within scope; educate; refer or coordinate with other providers |
| Monitor and follow up | Reassess against the defined parameters and adjust; document the outcome |
The step most often skipped, and the one examination items most often target, is the final one. A recommendation without a defined monitoring parameter and a date is an incomplete intervention.
Collecting: The Best Possible Medication History
A best possible medication history (BPMH) is a systematic, verified list of everything the patient actually takes — not what the profile says was dispensed.
Requirements:
- Use at least two sources, one of which must be the patient or caregiver. Other sources include the community dispensing record, a provincial drug information system, inspection of the vials the patient brought, the referring physician's list, and the previous discharge summary.
- Capture all categories: prescriptions, non-prescription products, natural health products, vitamins, inhalers, eye drops, topicals, patches, injectables, samples, and products borrowed from family.
- Record drug, dose, route, frequency, indication, duration, and actual use — including doses skipped, halved, or taken on demand.
- Use open-ended and normalising questions. "Many people miss doses; how many times in the last week did you miss the metformin?" gathers far more accurate information than "Are you taking your medications?"
Discrepancies found between the BPMH and the active orders are the raw material of medication reconciliation, covered in the expanded-scope section.
Assessing: Classifying Drug Therapy Problems
A drug therapy problem (DTP) is any undesirable event involving drug therapy that interferes with a desired outcome. Every DTP fits one of four categories:
| Category | Problem types | Example |
|---|---|---|
| Indication | Unnecessary therapy; needs additional therapy | A proton pump inhibitor continued four years after the reason ended; a post-myocardial-infarction patient with no statin |
| Effectiveness | Ineffective drug; dose too low | An antibiotic that does not cover the likely organism; levothyroxine at a dose leaving thyroid-stimulating hormone raised |
| Safety | Adverse drug reaction; dose too high | Dry cough on an ACE inhibitor; gabapentin at a full dose in stage G4 kidney disease |
| Adherence | Patient cannot or does not take the drug as intended | An inhaler the patient cannot actuate; a drug the patient cannot afford |
State the problem in a disciplined form: the drug, the problem, and the clinical consequence, plus the cause. "Amlodipine is causing ankle edema, which has led the patient to stop taking it, and the blood pressure is now uncontrolled" is assessable. "Possible side effect" is not.
Prioritise by risk of harm. An interaction that could cause bleeding or serotonin syndrome outranks an inconvenient dosing schedule, and an untreated urgent indication outranks both.
Planning: Goals, Alternatives, and Monitoring
Therapeutic goals must be specific, measurable, and time-bound, and they must be agreed with the patient. "Improve blood pressure" is not a goal. "Reduce home systolic blood pressure below 135 mmHg within eight weeks without orthostatic symptoms" is.
Select therapy by considering, in order: the patient's goals and values, efficacy for this indication, safety in this patient's comorbidities and organ function, interactions, ease of use, and cost and coverage. The last of these is a genuine clinical variable — a therapy the patient cannot afford has an effectiveness of zero.
Define monitoring parameters as pairs of efficacy and safety measures with a frequency:
| Therapy | Efficacy parameter | Safety parameter |
|---|---|---|
| ACE inhibitor for heart failure | Symptoms, weight, blood pressure | Potassium and creatinine 1 to 2 weeks after each change |
| Levothyroxine | Symptoms, thyroid-stimulating hormone at 6 to 8 weeks | Palpitations, atrial fibrillation, bone density with over-replacement |
| Warfarin | International normalized ratio in target range | Bleeding signs, hemoglobin |
| Methotrexate weekly | Joint counts, function | Complete blood count, liver enzymes, creatinine |
Implementing and Documenting
Implementation includes what the pharmacist does directly and what is handed off. Within an expanded scope a pharmacist may adapt, renew, or initiate therapy under provincial authority; outside it, the intervention is a clear, documented, actionable recommendation to the prescriber.
Document in SOAP format:
- S — Subjective: what the patient reports (symptoms, adherence, preferences).
- O — Objective: measurable data (vital signs, laboratory results, dispensing history, weights).
- A — Assessment: the pharmacist's clinical interpretation and the identified drug therapy problems.
- P — Plan: what was done or recommended, the monitoring parameters, patient education given, and the follow-up date.
Documentation is a professional and legal obligation. It transfers care safely, evidences the standard of practice met, and is the record examined if care is later questioned. Record the rationale for a decision, not only the decision, and record recommendations that were declined along with the reason.
Monitoring and Follow-Up
Set the follow-up interval from the pharmacology, not from convenience: 1 to 2 weeks after starting an ACE inhibitor for renal function and potassium, 6 to 8 weeks after a levothyroxine change for thyroid-stimulating hormone, 4 to 6 weeks after starting a statin for tolerability and lipids, and 1 to 2 weeks after an antidepressant change for early activation and suicidality risk in young adults.
At follow-up, close the loop explicitly: was the goal met, was the therapy tolerated, did any new drug therapy problem appear, and does the plan change? Then document and set the next review.
A pharmacist identifies that a patient's dry cough began two weeks after starting ramipril. Under the drug therapy problem framework, this is best classified as:
Which statement describes a correctly constructed best possible medication history?
A pharmacist recommends starting perindopril for a patient with heart failure. What must the care plan include to be complete?
In SOAP documentation, a patient's statement that she stops taking her diuretic on days she goes out belongs in which component?