17.1 The Patient Care Process: Assessment, Care Planning & Patient Interviewing

The Patient Care Process: Assessment, Care Planning & Patient Interviewing

In Canadian pharmacy practice, the delivery of clinical care has evolved from product-centered dispensing to a patient-centered professional practice model. Grounded in the philosophy of Pharmaceutical Care articulated by Hepler and Strand, and standardized by the National Association of Pharmacy Regulatory Authorities (NAPRA) and the Pharmaceutical Care Network Europe (PCNE), the pharmacist's primary professional obligation is to optimize therapeutic outcomes and enhance patient quality of life through the systematic prevention, identification, and resolution of Drug Therapy Problems (DTPs).

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The Patient Care Process Cycle

The Patient Care Process is an iterative, collaborative continuum comprising four distinct, interdependent phases:

                        THE PATIENT CARE PROCESS CYCLE

                     ┌────────────────────────────────┐
                     │        1. ASSESSMENT           │
                     │ • Patient History & Chief Cmp  │
                     │ • Medication Recon (BPMH)      │
                     │ • DTP Identification (7 Types) │
                     └───────────────┬────────────────┘
                                     │
                                     ▼
                     ┌────────────────────────────────┐
                     │      2. CARE PLAN CREATION     │
                     │ • Prioritize DTPs (Urgency)    │
                     │ • Establish SMART Goals        │
                     │ • Select Interventions (Rx/Non)│
                     └───────────────┬────────────────┘
                                     │
                                     ▼
                     ┌────────────────────────────────┐
                     │       3. IMPLEMENTATION        │
                     │ • Informed Patient Consent     │
                     │ • Prescriber Collaboration     │
                     │ • Clinical Documentation (SOAP)│
                     └───────────────┬────────────────┘
                                     │
                                     ▼
                     ┌────────────────────────────────┐
                     │   4. FOLLOW-UP & EVALUATION    │
                     │ • Monitor Efficacy & Endpoints │
                     │ • Monitor Safety & Toxicities  │
                     │ • Reassess & Modify Regimen    │
                     └───────────────┬────────────────┘
                                     │
                                     └──────── (Iterative Loop)

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Phase 1: Patient Assessment & Best Possible Medication History (BPMH)

The assessment phase forms the diagnostic foundation of clinical decision-making. The pharmacist gathers subjective and objective information to understand the patient's medical status, health beliefs, and pharmacotherapeutic history.

Core Assessment Data Components

1. Chief Complaint (CC) & History of Present Illness (HPI): The primary reason the patient is seeking care, characterized by onset, location, duration, character, aggravating/alleviating factors, and radiation (OLDCARTS).
2. Past Medical History (PMHx): Confirmed chronic and acute medical diagnoses, surgical history, and hospitalizations.
3. Allergies & Intolerances: Crucial distinction between true immune-mediated allergies (IgE-mediated anaphylaxis, urticaria, angioedema, bronchospasm) and adverse drug intolerances / side effects (e.g., nausea from codeine, dry cough from ACE inhibitors, mild dyspepsia from NSAIDs). The pharmacist must record the specific agent, the exact clinical manifestation, the date of onset, and whether re-exposure occurred.
4. Social & Lifestyle History (SHx): Tobacco use (packs/day, pack-years), alcohol intake, recreational substance use, cannabis consumption, occupation, functional independence, living arrangements, and dietary patterns.
5. Family History (FHx): Premature atherosclerotic cardiovascular disease (ASCVD), diabetes, endocrine disorders, malignant hyperthermia, or pharmacogenomic anomalies.
6. Review of Systems (ROS) & Objective Data: Vital signs (blood pressure, heart rate, respiratory rate, temperature, SpO2), anthropometric measurements (height, weight, body mass index [BMI]), and diagnostic laboratory values (serum creatinine, eGFR, electrolytes, HbA1c, liver enzymes, complete blood count).

Medication Reconciliation & Best Possible Medication History (BPMH)

Medication reconciliation is a formal collaborative process designed to prevent medication errors at care interfaces (hospital admission, intra-hospital transfer, and discharge). In accordance with standards from Healthcare Excellence Canada (formerly the Canadian Patient Safety Institute):

BPMH Methodology Standards

• Structured Clinical Interview: Pharmacists (or trained pharmacy technicians) conduct a dedicated interview with the patient, family member, or substitute decision-maker (SDM).
• Mandatory Secondary Source Verification: A BPMH cannot rely solely on patient recall. The clinician must cross-reference and verify the regimen against at least one reliable secondary source:
  • Provincial electronic drug information systems (e.g., PharmaNet in BC, Netcare in Alberta, ConnectingOntario/DHDR in Ontario, DIS in Nova Scotia);
  • Physical inspection of current prescription vials brought in by the patient;
  • Direct telephone contact with the patient's regular community pharmacy;
  • Primary care provider records or recent hospital discharge summaries.
• Discrepancy Analysis: The pharmacist identifies and reconciles discrepancies between the BPMH and newly written admission orders, categorizing discrepancies as:
  • Intentional Discrepancies: Deliberate clinical changes documented by the prescriber (e.g., withholding an ACE inhibitor during acute dehydration or sepsis);
  • Unintentional Discrepancies: Medication errors resulting from omissions, duplicate therapies, incorrect dosages, or unrecognized drug-drug interactions.

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Systematic Drug Therapy Problem (DTP) Categorization

A Drug Therapy Problem (DTP) is any undesirable event experienced by a patient that involves, or is suspected to involve, drug therapy, and that actually or potentially interferes with achieving desired health outcomes. The standard Canadian pharmaceutical care framework categorizes DTPs into 7 discrete types grouped under four therapeutic pillars: Indication, Effectiveness, Safety, and Adherence.

                       THE 7 DRUG THERAPY PROBLEMS (DTPs)

           INDICATION                        EFFECTIVENESS
  ┌───────────────────────────┐      ┌───────────────────────────┐
  │ 1. Unnecessary Drug       │      │ 3. Wrong / Inappropriate  │
  │    - No valid indication  │      │    - Ineffective drug     │
  │    - Duplicate therapy    │      │    - Dosage form wrong    │
  │    - Prescribing cascade  │      │    - Contraindication     │
  ├───────────────────────────┤      ├───────────────────────────┤
  │ 2. Requires Additional    │      │ 4. Dosage Too Low         │
  │    - Untreated condition  │      │    - Dose/frequency low   │
  │    - Prophylaxis needed   │      │    - Duration too short   │
  │    - Synergistic therapy  │      │    - Subtherapeutic TDM   │
  └───────────────────────────┘      └───────────────────────────┘

             SAFETY                            ADHERENCE
  ┌───────────────────────────┐      ┌───────────────────────────┐
  │ 5. Dosage Too High        │      │ 7. Non-Adherence          │
  │    - Toxicity risk / dose │      │    - Unwilling (beliefs)  │
  │    - Duration excessive   │      │    - Unable (cost/memory) │
  │    - Supratherapeutic TDM │      │    - Physical barriers    │
  ├───────────────────────────┤      └───────────────────────────┘
  │ 6. Adverse Drug Reaction  │
  │    - Hypersensitivity/ADR │
  │    - Drug-drug interaction│
  │    - Idiosyncratic toxic  │
  └───────────────────────────┘

Detailed Analysis of the 7 DTP Categories

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Phase 2: Care Plan Development & SMART Goals of Therapy

Once DTPs are identified, the pharmacist collaborates with the patient and healthcare team to formulate a personalized Care Plan.

Prioritizing Drug Therapy Problems

When multiple DTPs co-exist, the pharmacist must establish clinical triage priorities:

1. Urgent / Safety-Critical Priorities: Any DTP presenting an immediate risk of severe morbidity, toxicity, or mortality (e.g., acute hyperkalemia from spironolactone + ACEi, toxic digoxin levels, severe bleeding on anticoagulation, anaphylaxis, untreated severe sepsis). These demand immediate same-day intervention.
2. High-Priority Therapeutic Needs: Subtherapeutic control of an active, unstable clinical condition (e.g., uncontrolled asthma exacerbation, severe depressive episode, blood pressure > 180/110 mmHg).
3. Medium-Priority Preventive / Optimization Needs: Initiation of chronic disease prevention (e.g., adding a statin or SGLT2 inhibitor in stable diabetes, immunizations, osteoporosis prophylaxis).
4. Low-Priority Routine Maintenance: Minor non-adherence, switching to generic formulations for cost-savings, or routine dose timing adjustments.

Formulating SMART Goals of Therapy

Every care plan requires clearly delineated therapeutic goals established collaboratively with the patient:

                      SMART GOALS OF THERAPY FRAMEWORK

  S ── SPECIFIC: Clearly define the biological parameter or symptom targeted.
  M ── MEASURABLE: Establish quantifiable clinical biomarkers or validated scale scores.
  A ── ACHIEVABLE: Realistic considering patient frailty, comorbidities, and life expectancy.
  R ── RELEVANT: Matched to patient preferences, functional capacity, and mortality reduction.
  T ── TIME-BOUND: Explicit chronological milestones for re-evaluation and follow-up.

• Clinical / Biomarker Endpoints: Surrogate physiological markers (e.g., reduce resting BP to < 130/80 mmHg within 4 weeks; reduce HbA1c to <= 7.0% within 3 months; maintain INR between 2.0 and 3.0).
• Patient-Reported / Humanistic Endpoints: Functional quality-of-life goals (e.g., eliminating nocturnal angina attacks to allow walking 2 kilometers daily; reducing Osteoarthritis Knee Pain Score from 8/10 to <= 3/10; restoring unbroken 7-hour nocturnal sleep).

Selecting Interventions

The care plan must incorporate both:

• Pharmacological Interventions: Dose titration, drug discontinuation, therapeutic substitution, initiation of new agents, or alteration of dosage forms.
• Non-Pharmacological Interventions: Medical nutrition therapy, sodium restriction (< 2,000 mg/day for hypertension), smoking cessation counselling, physical therapy, exercise prescriptions, and fluid management.

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Phase 3: Implementation & Clinical Documentation

Implementation translates the care plan into action through patient engagement, prescriber collaboration, and formal legal documentation.

Informed Patient Consent

Before implementing any therapeutic change or pharmacist prescribing intervention, the pharmacist must obtain informed consent by explaining:

• The nature, rationale, and expected clinical benefits of the proposed intervention;
• Potential material risks, common adverse effects, and rare but serious toxicities;
• Available therapeutic alternatives (including non-pharmacological options);
• The clinical prognosis and likely consequences of declining treatment.

Prescriber Collaboration & Clinical Communication

When communicating recommendations to physicians or nurse practitioners, the pharmacist must present a concise, evidence-based rationale, referencing clinical practice guidelines and proposing actionable alternatives.

Standardized Documentation: SOAP vs. FARM Frameworks

In Canada, clinical pharmacist documentation in hospital health records and community pharmacy systems follows standardized formats to ensure professional accountability and continuity of care:

                      CLINICAL DOCUMENTATION FRAMEWORKS

          SOAP FRAMEWORK                             FARM FRAMEWORK
  ┌─────────────────────────────────┐       ┌─────────────────────────────────┐
  │ S ── Subjective (Patient Report)│       │ F ── Findings (Clinical Data)   │
  │ O ── Objective (Labs, Vitals)   │       │ A ── Assessment (DTP Evaluation)│
  │ A ── Assessment (DTP Analysis)  │       │ R ── Resolution (Action Plan)   │
  │ P ── Plan (Interventions & F/U) │       │ M ── Monitoring (Endpoints/Time)│
  └─────────────────────────────────┘       └─────────────────────────────────┘

The SOAP Note Architecture:

• Subjective (S): Information communicated directly by the patient, caregiver, or family. Includes the chief complaint, history of present illness in the patient's own words, pain ratings (0–10 scale), reported adherence, lifestyle factors, and review of subjective symptoms.
• Objective (O): Directly observable, verifiable, and measurable data. Includes vital signs (BP, HR, RR, temp), physical assessment findings, diagnostic imaging results, laboratory values (with reference ranges and dates), and current verified medication profiles.
• Assessment (A): The pharmacist's clinical evaluation. Identifies and describes each specific DTP, providing a critical evaluation of etiology, guideline concordance, drug interactions, and therapeutic alternatives considered.
• Plan (P): The precise, actionable steps to be executed. Details medications prescribed, modified, or deprescribed; patient education delivered; non-pharmacological instructions; and a detailed monitoring and follow-up plan specifying exact parameters, targets, and chronological timelines.

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Phase 4: Follow-up and Evaluation

A care plan is dynamic. The follow-up phase evaluates the patient's actual response to therapy, assessing both efficacy and safety:

1. Evaluating Therapeutic Efficacy: Has the desired clinical goal been achieved? (e.g., Has blood pressure normalized? Have depressive symptoms remitted on the PHQ-9 scale? Has the bacterial infection resolved?).
2. Evaluating Safety & Tolerability: Has the patient experienced any new, emergent, or worsening adverse drug reactions? Are laboratory safety panels stable? (e.g., monitoring serum potassium and creatinine 1–2 weeks after initiating an ACE inhibitor or mineralocorticoid receptor antagonist; checking liver transaminases or creatine kinase if myalgia occurs on statin therapy).
3. Reassessing Adherence: Is the patient encountering administration difficulties, financial barriers, or unexpected side effects that impede continued compliance?
4. Care Plan Modification: If therapeutic goals are not attained or toxicities emerge, the pharmacist adjusts the care plan, titrating doses, discontinuing offending agents, or switching to alternative evidence-based therapies.

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Patient Interviewing Techniques & Motivational Interviewing (MI)

Effective interpersonal communication is vital to accurate clinical assessment and patient adherence.

Interviewing Fundamentals

• Open-Ended vs. Closed-Ended Questions:
  • Open-Ended Questions: Begin with "What", "How", or "Describe". These encourage the patient to share extensive clinical narrative, uncover underlying health beliefs, and reveal lifestyle context (e.g., "What challenges have you experienced when taking your evening doses?").
  • Closed-Ended Questions: Elicit brief "yes", "no", or single-word factual responses. Best utilized to clarify specific factual data points, confirm dosing numbers, or rule out acute medical red flags (e.g., "Did you take your medication this morning?" or "Are you experiencing chest pain right now?").
• Active Listening Skills: Non-verbal attending (maintaining professional eye contact, leaning forward, open posture), strategic use of silence (allowing the patient time to reflect and formulate responses without premature interruption), paraphrasing, and emotional validation.

Motivational Interviewing (MI) Principles

Developed by William R. Miller and Stephen Rollnick, Motivational Interviewing (MI) is a collaborative, person-centered counselling approach designed to strengthen personal motivation for, and commitment to, a specific health behavior change by exploring and resolving ambivalence.

The Core Principles of Motivational Interviewing (REDS)

                         THE REDS PRINCIPLES OF MI

  R ── ROLL WITH RESISTANCE: Avoid arguing; reframe resistance as healthy hesitation.
  E ── EXPRESS EMPATHY: Non-judgmental active listening; validate feelings and reality.
  D ── DEVELOP DISCREPANCY: Highlight gaps between core values and current health behaviors.
  S ── SUPPORT SELF-EFFICACY: Reinforce the patient's personal belief in their capacity to succeed.

1. Roll with Resistance: Confronting, arguing, or attempting to coerce the patient produces defensive "sustain talk." Instead, the clinician invites the patient to explore their own perspectives without pushback.
2. Express Empathy: Clinicians demonstrate deep, non-judgmental acceptance, validating the patient's struggles through reflective listening.
3. Develop Discrepancy: The clinician helps the patient recognize the profound discrepancy between their deeply held personal values (e.g., wanting to live long enough to attend their grandchildren's graduations) and their current behaviors (e.g., omitting insulin or continuing tobacco use).
4. Support Self-Efficacy: Clinicians bolster the patient's confidence and autonomy, highlighting past successes and reinforcing that the patient—not the clinician—holds the power to achieve lasting change.

The OARS Communication Skills

The operational tools utilized during Motivational Interviewing are encapsulated by the OARS mnemonic:

                              THE OARS FRAMEWORK

       SKILL                  PURPOSE                         CLINICAL SCRIPT EXAMPLE
┌─────────────────┬───────────────────────────────┬──────────────────────────────────────────┐
│ O ── Open       │ Elicits the patient's inner   │ "What thoughts do you have about         │
│    Questions    │ thoughts, beliefs, and goals. │ starting insulin to manage your sugars?" │
├─────────────────┼───────────────────────────────┼──────────────────────────────────────────┤
│ A ── Affirm     │ Validates efforts, builds     │ "You've done an impressive job tracking  │
│                 │ self-efficacy and resilience. │ your daily blood pressures this month."  │
├─────────────────┼───────────────────────────────┼──────────────────────────────────────────┤
│ R ── Reflective │ Demonstrates empathy, clarifies│ "You feel overwhelmed by the number of   │
│      Listening  │ meaning, reframes concerns.   │ pills you have to take every morning."   │
├─────────────────┼───────────────────────────────┼──────────────────────────────────────────┤
│ S ── Summarize  │ Consolidates discussion,      │ "So far, you've shared that while cost   │
│                 │ highlights 'change talk'.     │ is a major hurdle, protecting your heart │
│                 │                               │ is your top priority. Did I get that?"   │
└─────────────────┴───────────────────────────────┴──────────────────────────────────────────┘

• Eliciting Change Talk (DARN-CAT): Clinicians listen for and actively elicit statements that favor health change, categorized into preparatory change talk (Desire, Ability, Reasons, Need) and mobilizing change talk (Commitment, Activation, Taking steps). When the patient voices their own reasons for change, behavioral transformation is significantly more durable.

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Clinical Case Scenario: Comprehensive DTP Assessment and Care Plan in Polypharmacy

A 68-year-old male retired carpenter presents to the ambulatory care pharmacy clinic for a comprehensive medication review. He has a 12-year history of Type 2 Diabetes Mellitus, primary hypertension, and severe osteoarthritis of both knees. His current vital signs and laboratory findings show: Blood Pressure 148/88 mmHg, Heart Rate 72 bpm, HbA1c 8.4%, Serum Creatinine 115 µmol/L, eGFR 52 mL/min/1.73m² (baseline was 74 mL/min one year ago), and Serum Potassium 4.6 mmol/L.

Medication Regimen Disclosed During BPMH:

1. Metformin 1,000 mg PO BID;
2. Amlodipine 10 mg PO daily;
3. Furosemide 20 mg PO daily (started 2 months ago by a walk-in clinic);
4. OTC Ibuprofen 400 mg PO TID PRN (patient takes 1,200 mg daily for knee pain);
5. Gliclazide MR 60 mg PO daily in the morning.

Pharmacist Clinical Assessment & DTP Identification:

                         CASE DTP IDENTIFICATION MATRIX

  DTP 1: UNNECESSARY DRUG THERAPY (Prescribing Cascade)
  • Offending Issue: Furosemide 20 mg daily was added to treat bilateral peripheral ankle edema
    induced by high-dose Amlodipine (10 mg daily), rather than fluid overload.
  • Resolution: Taper and discontinue Furosemide; reduce Amlodipine to 5 mg daily or replace with an ACEi/ARB.

  DTP 2: WRONG / INAPPROPRIATE DRUG & SAFETY RISK
  • Offending Issue: Chronic high-dose OTC Ibuprofen (1,200 mg/day) in a patient with CKD (eGFR 52),
    hypertension, and diabetes. NSAID use is precipitating acute-on-chronic renal decline (eGFR drop),
    elevating blood pressure via renal prostaglandin inhibition, and escalating cardiovascular risk.
  • Resolution: Discontinue Ibuprofen; transition to topical NSAIDs (voltaren emulgel), acetaminophen,
    or non-pharmacological physiotherapy.

  DTP 3: REQUIRES ADDITIONAL DRUG THERAPY (Guideline-Directed Medical Therapy)
  • Offending Issue: Absence of an ACE inhibitor or ARB for nephroprotection in a hypertensive diabetic;
    absence of a statin for vascular protection (Diabetes Canada: age >= 40 indicates statin therapy);
    absence of an SGLT2 inhibitor (indicated for T2D with CKD to slow renal decline and lower HbA1c).
  • Resolution: Initiate Ramipril 5 mg daily (titrate to 10 mg), Atorvastatin 20 mg daily,
    and Empagliflozin 10 mg daily.

SOAP Clinical Progress Note:

• Subjective (S): 68-year-old male reports persistent knee stiffness and aching (6/10 pain score) managed with daily OTC ibuprofen. Notes mild bilateral ankle swelling that began several months ago. Denies orthopnea, paroxysmal nocturnal dyspnea, or chest discomfort. Expresses motivation to prevent kidney complications.
• Objective (O): BP 148/88 mmHg, HR 72 bpm. Weight 88 kg, BMI 28.4 kg/m². Labs: HbA1c 8.4%, SCr 115 µmol/L, eGFR 52 mL/min/1.73m², K+ 4.6 mmol/L. Verified BPMH shows 5 medications including chronic ibuprofen 1,200 mg/day and furosemide 20 mg/day.
• Assessment (A):
  1. Uncontrolled Hypertension and CKD Progression: Blood pressure exceeds Diabetes Canada target (< 130/80 mmHg). Renal decline (eGFR 52 mL/min) is aggravated by chronic systemic NSAID ingestion. Furosemide represents unnecessary drug therapy treating amlodipine-induced vasodilation (prescribing cascade).
  2. Suboptimal Glycemic Control: HbA1c 8.4% exceeds individualized target of < 7.0%.
  3. Unaddressed Vascular Protection: Patient lacks guideline-indicated statin and ACE inhibitor/ARB therapy.
• Plan (P):
  1. Deprescribing Interventions: Discontinue OTC ibuprofen immediately to restore renal perfusion. Discontinue furosemide 20 mg daily; reduce amlodipine from 10 mg to 5 mg daily to mitigate peripheral edema.
  2. Therapeutic Additions: Initiate Ramipril 5 mg PO once daily (target 10 mg daily) for renal and blood pressure control. Initiate Empagliflozin 10 mg PO once daily to optimize glycemic control (HbA1c target < 7.0%) and provide cardiorenal protection. Initiate Atorvastatin 20 mg PO once daily for primary ASCVD vascular protection.
  3. Analgesic Management: Recommend topical Diclofenac 1.16% gel applied QID to both knees (minimal systemic absorption) and refer to community physiotherapy for quad-strengthening exercises.
  4. Monitoring & Follow-up: Re-check serum creatinine, eGFR, and electrolytes in 10 to 14 days following ramipril and empagliflozin initiation. Repeat blood pressure check in 2 weeks (target < 130/80 mmHg). Re-evaluate HbA1c in 3 months.