The Patient Care Process & Care Planning written by Dr. Nehad Ahmed using DeepSeek

 

The Patient Care Process & Care Planning

The patient care process is a foundational, cyclical method consisting of three core components:

1. Assessment: Collecting and analyzing patient, disease, and drug information to identify the patient's drug-related needs and existing or potential DTPs.

2. Care Plan Creation: Collaboratively developing a plan with the patient to resolve DTPs and achieve therapeutic goals.

3. Follow-up Evaluation: Monitoring the patient's progress and adjusting the plan as needed.

Key Elements of a Care Plan:

• Medical Condition: The specific diagnosis being addressed.

• Drug Therapy Problem: The specific DTP related to that condition (e.g., unnecessary therapy, ineffective drug, dosage too low, nonadherence).

• Goals of Therapy: Should be Specific, Measurable, Achievable, and have a defined Timeline (SMART).

• Interventions: The specific actions taken or recommended to resolve the DTP.

• Follow-up Plan: A schedule for reassessment and monitoring.

Part 2: Documentation of Interventions

Documentation is critical for communication, legal purposes, billing, and demonstrating the value of pharmacy services.

Two Primary Documentation Formats are Presented:

1. SOAP Note: A widely used format in healthcare.

   • S (Subjective): Patient's symptoms, concerns, and history.

   • O (Objective): Measurable data like lab values, physical exam findings.

   • A (Assessment): The clinician's diagnosis or evaluation of the problem.

   • P (Plan): The actions to be taken, including treatments and monitoring.

2. FARM Note: A pharmacist-specific alternative.

   • F (Findings): Combines subjective and objective data.

   • A (Assessment): Evaluation of the DTP and its urgency.

   • R (Resolution): Actions taken or recommended to solve the problem.

   • M (Monitoring): Parameters and schedule for follow-up.

Key Takeaways

• Systematic Approach: The patient care process provides a logical framework to ensure consistent, comprehensive care.

• Patient-Centeredness: The patient is an active participant in developing their care plan.

• Problem-Focused: Care revolves around identifying, resolving, and preventing DTPs.

• Documentation is Essential: The mantra "if it isn't documented, it didn't happen" underscores the necessity of recording all care activities.

• Dynamic Process: Care planning is not a one-time event but an ongoing process that adapts to the patient's changing needs.

• Standardization Evolving: While pharmacy lacks a single universal documentation standard, formats like SOAP and FARM provide structured methods for recording interventions, with a shift towards electronic medical records (EMRs)