SOP For Clinical Pharmacy

STANDARD OPERATING
PROCEDURES FOR THE

PROVISION OF CLINICAL
PHARMACY SERVICES
FIRST EDITION
Abstract
MOH/GHS
[Email address]
STATEMENT OF PURPOSE
“It is within the Pharmacists’ scope of practice in all practice settings to obtain
medication histories, review patients medication to identify medication-related
problems, intervene with the Physician to resolve identified problems, educate
the patient about proper use of medications, encourage adherence with
prescribed medications, and document and communicate information to the
Physician. These medication therapy management (MTM) activities are part of
the Pharmacists’ responsibility to ensure optimal therapeutic outcomes for
patients they serve”
The Ashville Project & Medicare Modernization Act
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ACRONYMS
ADE Adverse Drug Event
ADR Adverse Drug Reaction
BSA Body Surface Area
CEO Chief Executive Officer
DTC Drugs & Therapeutics Committee
DTP Drug Therapy Problem
FIP International Pharmaceutical Federation
FDA Food and Drugs Authority
MDT Multidisciplinary Team
MOH Ministry of Health
OTC Over-The –Counter
PC Pharmacy Council
PCP Pharmaceutical Care Plan
POM Pharmacy Only Morning Session
POR Pharmacy Only Round
SOP Standard Operating Procedure
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Table of Contents
STATEMENT OF PURPOSE ........................................................................................................................1
ACRONYMS ...........................................................................................................................................2
FOREWORD ..........................................................................................................................................5
Acknowledgements .................................................................................................................................6
SECTION ONE ...........................................................................................................................................7
PROVISION OF PHARMACEUTICAL CARE .................................................................................................7
INTRODUCTION ...................................................................................................................................8
Scope of the Manual ............................................................................................................................9
Purpose of the Manual .........................................................................................................................9
Objectives of the Manual .....................................................................................................................9
THE PHARMACEUTICAL CARE PROCESS ....................................................................................10
STANDARD OPERATING PROCEDURES .......................................................................................19
3.1 Assessment ..................................................................................................................................19
3.1.1 Collection of Patient-Specific Information/Data ...........................................................19
3.1.2 Identification of drug therapy problems ........................................................................21
3.2 Development and Implementation of a Pharmaceutical Care Plan .............................................23
3.2.1 Goals of Therapy ...............................................................................................................23
3.2.2 Intervention/Implementation .........................................................................................24
3.3 Follow Up ..............................................................................................................................25
Introduction .......................................................................................................................................25
3.4 Monitoring and evaluation ...........................................................................................................27
3.5 Discharge Planning and Counselling for inpatients ...............................................................28
3.5 Pharmacy Only Ward Rounds and Morning Sessions ...........................................................29
3.5.1 Pharmacy Only Morning Session Activity ......................................................................29
3.5.2 Pharmacy Only Ward Round Activities ..........................................................................30
3.5.3 After POM and POR .......................................................................................................31
3.6 Multidisciplinary Team Activities .........................................................................................31
3.6.1 Multidisciplinary Team Round ......................................................................................31
3.6.2 Multidisciplinary Team Morning Session .....................................................................32
SOPs FOR DOCUMENTING AND REPORTING PHARMACEUTICAL CARE ............................33
4.1 Patient Medication Profile Form (Form 1) ............................................................................35
4.2 Pharmaceutical Care Progress Notes Recording Sheet................................................................43
4.3 Medication Reconciliation Form .................................................................................................46
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4.4 Medication Information Record ..................................................................................................50
4.5 Pharmaceutical Care Interventions Daily Summary..............................................................55
4.5.1. Daily Direct Patient Care Interventions Summary ..............................................................56
4.6 Pharmaceutical Care Interventions Monthly Summary and Reporting Form ...................57
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FOREWORD
Involvement of pharmacists in patient care (pharmaceutical care services) is a key
intervention procedure in all contemporary healthcare institutions. The principal
objective is to optimize the outcomes of medicine therapy, minimize possible
toxicities and to generally improve the quality of patient care
As part of the efforts to advance and showpiece the practice of pharmaceutical

care, it has become necessary to produce a guiding document to standardize
pharmaceutical services provided in the Healthcare institutions nationwide.
This manual, will contribute to the standardization of the provision of

pharmaceutical care in the country
The manual contains the step to step procedures for the provision of
pharmaceutical care for patients, along with the necessary documentation and
reporting. This documents has been reviewed by seasoned clinical pharmacists
and other practicing pharmacy experts. Health facilities should incorporate the
use of these guidelines into daily service provision. This manual though not
exhaustive, should facilitate the process of documentation and reporting of
pharmaceutical care services
It is expected that practicing pharmacists, pharmacy students, health system

managers, researchers and experts involved in education, mentoring and
supervision of pharmaceutical services will find this manual useful, especially in
service provision, management, education, research and monitoring and
evaluation purposes in relation to pharmaceutical care services.
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Acknowledgements
The review of the Standard Operating Procedure for the Provision of Pharmaceutical Care in
Health Institutions services has been successfully completed as a result of the recommendations
and contributions received from:
Pharm Dr. Raymond Tetteh – Consultant Clinical Pharmacist, Korle Bu Teaching hospital
Pharm Dr. Phillip Anum- Consultant Clinical Pharmacist, Ghana National Drug Information
Services
Pharm Mrs F. Amah Nkansah - Consultant Clinical Pharmacist/ Deputy Director of Pharmacy
Services, Korle-Bu Teaching Hospital
C/Supt Pharm Ellen Sam- Specialist Clinical Pharmacist, Police Hospital
Pharm Dorcas Boateng- Specialist Clinical Pharmacist, Korle-Bu Teaching Hospital
Pharm Isaac Adupong- Communication Consultant, Blazing Impact Consult
Pharm Mrs. Obedia Akweley Seaneke- Specialist Clinical Pharmacist, Korle- Bu Teaching
Hospital
Pharm Dr. Marc Dzradosi- Specialist Clinical Pharmacist, Central University
Pharm Ruby Awittor- Deputy Director Pharmaceutical services, Ghana Health Service
Pharm Dr Franklin Acheampong- Head of Research, Korle-Bu Teaching Hospital
Pharm Charles Agyeman Fordjour – Chairman, Strategic Planning committee
Pharm Cynthia Akumanue - Principal Pharmacist- Tamale Teaching Hospital
Pharm Kofi Boamah Mensah. - Komfo Anokye Teaching Hospital
Pharm Hamidu Abdulai- Director of Pharmacy Services, Tamale Teaching Hospital
Pharm Joseph Turkson- Cape coast Teaching Hospital
Pharm Bernard Agyei-Kwanin- Project Coordinator, SP
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SECTION ONE
PROVISION OF PHARMACEUTICAL CARE
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INTRODUCTION
Background
The philosophy of Pharmaceutical Care, which is defined by the International

Pharmaceutical Federation (FIP) as “the responsible provision of
pharmacotherapy for the purpose of achieving definite outcomes that improves
or maintains a patient’s quality of life”. Pharmaceutical Care therefore blends
caring orientation (patients) with specialized therapeutic knowledge, experience
and judgement for the purpose of ensuring optimal patient outcomes
A paradigm shift for the profession of pharmacy over the last three decades
necessitated a move from medicine supply oriented practice to a more inclusive
focus on patients. Our role has evolved from compounder and supplier of
pharmaceutical products to that of a provider of services and information and
lately to a provider of patient care. Currently the role of the pharmacist is to ensure
that a patients’ medicine therapy is safe, efficacious and cost effective By directly
getting involved in the individual patients’ medicine related needs and exhibiting
responsibility, pharmacists make unique contribution to medicine therapy
outcomes as well as patients quality of life.
According to the National Standards of Pharmaceutical Practice in Public Health

Institutions in Ghana, all hospitals provide Pharmaceutical Care services as part
of pharmacy services. It presents Pharmaceutical care as patient oriented services
developed to promote the rational use of medicines, maximize therapeutic
benefits, minimize risk, reduce cost and support patient choice and decisions,
thereby ensuring the safe, effective and economic use of medicine treatment in
individual patients.
As Pharmacists, we are expected to:
• Collaborate with doctors, nurses, and other health care professionals on the
therapeutic use of medicines, to include their cost effectiveness and safety
• Provide direct patient care services to include medication history taking,
medicines education and advice and patient therapy monitoring.
• Support hospital and clinical managers with appropriate advice to enable

them make informed decisions with respect to medicines and guidelines
designed to ensure safety, cost-effectiveness and efficacious in medicine
use.
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This manual has been developed to standardize and formalize the provision of
pharmaceutical care services for patients, and to document and report the services
provided.
Scope of the Manual
This manual describes the specific steps pharmacists take in providing
pharmaceutical care services to patients in healthcare institutions. It contains
Standard Operating Procedures (SOPs) for the provision of Pharmaceutical Care
(PC) services to patients, with the necessary documentation and reporting systems
Purpose of the Manual
This manual describes specific procedures in pharmaceutical care practice. It is
intended to be used as a hands-on reference for pharmacists providing
Pharmaceutical Care thereby supporting standardization of practice. This will
lead to an ultimate goal of optimizing patient care in health facilities. As indicated
earlier, this document provides evidence for management to evaluate and audit
Pharmaceutical Care. The manual will be used as reference material for health
system managers, policymakers, health care providers, researchers and pharmacy
students.
Objectives of the Manual

Main Objective
To standardize the provision of Pharmaceutical Care services with the aim of

optimizing patient outcomes by ensuring the Rational Use of Medicines
Specific Objectives
• To Ensure that standardized Pharmaceutical Care services are provided in

all healthcare institutions at all times
• To clarify roles and responsibilities of pharmacists providing
pharmaceutical care
• To Provide a detailed description of how to perform Pharmaceutical Care
activities
• To serve as a training tool for pharmacists
• To Provide evidence of commitment to improvements in the quality of
patient care
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THE PHARMACEUTICAL CARE PROCESS
The delivery of effective pharmaceutical care to patients requires that pharmacists
use their time effectively and demonstrate their responsibility and
resourcefulness. A systemic approach to the delivery of pharmaceutical care
involves the following four (4) steps
• Step 1: Assess the patients medicine therapy needs and identify

actual and potential Drug Therapy Problems ( DTP)
• Step 2: Develop a care plan to resolve and /or prevent the DTPs
• Step 3: Implement the care plan
• Step 4: Evaluate and review the care plan
To achieve this
1. A professional relationship must be developed with the patient/ the

caregiver
2. Patient specific information must be collected, organised, recorded and
maintained
3. Patient-specific medical information must be evaluated and a drug therapy
plan developed mutually with the patient and the healthcare team.
4. The pharmacist assures that the patient has medicines and medical devices,
information and knowledge necessary to carry out the medicine therapy
plan
5. The Pharmacist reviews, monitors and recommends modification to the
therapeutic plan as necessary and appropriate, and in concert with the
patient and healthcare team
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THE PHARMACEUTICAL CARE PROCESS
Access needs and Identify

1 Drug Therapy Problems
2 Develop a Care Plan
Patients
receiving or requiring
pharmaceutical Care
Implement the Care Plan

3
4 Monitor and Review the Care Plan
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STEPS TO PROVIDING PHARMACEUTICAL CARE
Data Collection
1. Review Patient Medical Record
2. Review Medication Profile
3. Interview Patient
4.
Develop or Identify the Pharmacotherapy Plan (CORE)
Identify the drug related problems or patient needs (PRIME)
Formulate a Pharmaceutical Care Plan

Follow Up
Communicate plan with Patient and Health Care Team
Document actions taken in Patient Medical Record
Adapted from American Hospital Association

CORE
C- Condition or patient need

O-Outcomes desired for the condition (patient and therapeutic endpoints)
R- Regimen selected to achieve that outcome
Therapy regimens-Existing therapy and existing therapy
Goal setting and behaviour regimen
E-Evaluation parameters to assess outcome achievement
Efficacy Parameters
Toxicity Parameters
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PRIME
Goal: identify actual or potential problem that could compromise the desired patient outcomes
P-Pharmaceutical based problems
R-Risks to the patient
I-Interaction
M-Mismatch between medication and condition or patient needs
E- Efficacy
ESTABLISH AND MAINTAIN A PROFESSIONAL RELATIONSHIP
STEP 1: Establish good communication with patient/ caregiver, and other

members of the health care team from the beginning in order for the pharmacists
to collect, synthesize and interpret relevant information. Take into account all
patient and medication factors that may predispose patients to the risk of DTPs.
Talk to patient/caregivers, consult colleague health professionals and review

patient medication and clinical records. DTPs are identified by analysing
sociological, pathophysiological and pharmacological knowledge of the patient,
disease, and medicine therapy information collected.
COLLECT, ORGANISE, RECORD AND MAINTAIN (CORM)

PATIENT SPECIFIC MEDICAL INFORMATION
STEP 2: Pharmacists must collect and/or generate subjective and objective

information regarding the patient's general health and activity status, Past
Medical History, Medicines History, Social History, diet and Family History,
History of Presenting Complaints, and (health insurance status).
It must be timely, accurate, and complete, and it must be organized and

recorded to ensure that it is readily retrievable and updated as necessary and
appropriate.
Pharmacists must ensure confidentiality in the care of the patients
STEP 3: Assess the patients medicine therapy needs and identify actual and
potential drug therapy problems
A DTP is any undesirable event experienced by a patient, which involves or is

suspected to involve, medicine therapy, and which interferes with the
achievement of the desired goals of therapy. A DTP is a clinical problem, and it
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should be identified and resolved like other clinical problems. It should be
emphasised that the most important role of the pharmacist is to prevent DTPs
from occurring. It is indeed the most valuable service that a pharmacist can
provide to his/her patient
There are seven categories of patients’ problems therefore seven types of DTPs.
These include any and all side effects, toxic reactions, treatment failures, or the
need for additive synergistic, or preventive medications, as well as non-
compliance. The seven categories are described in table 1.
The first two categories of DTP are associated with INDICATION. The third
and fourth categories with EFFECTIVENESS. The fifth and sixth categories are
associated with SAFETY and the seventh deals with patient COMPLIANCE.
DTPs can be resolved or prevented, similar to other clinical problems, unless the
cause of the problem is not clearly understood. It is therefore necessary to identify
and categorize not only the DTP, but also its most likely cause. This facilitates
the work of the pharmacist confidently in resolving or preventing the problem.
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Table 1. Categories and Common Causes of Drug Therapy Problems
Assessment Drug Therapy
PATIENT PROBLEM CAUSES

NEED
Appropriate Ineffective A medical condition requires Combination
indication Medicine therapy (synergistic or additive)
The medicine is not the most effective for the
management of the patient
Untreated Needs additional drug therapy Untreated indications
Indications Prophylactic therapy
Effectiveness Ineffectiveness The medicine is not effective/substandard
The condition is resistant to the medication
The dosage form is inappropriate
Dosage too low The dose is too low to give desired outcome
The dose intervals are too long
The duration of therapy is too short
A medicine interaction reduces serum
concentration of the drug
Safety Safety/ The medication causes an undesirable
Adverse Drug reaction reaction not related to dose
A safer medicine is needed due to patient
risk factors
A medicine interaction causes an undesirable
reaction
A medicine interaction causes a toxic
reaction to the medication
Dosage too high The dose is too high for the patient
The dosing frequency is too short
The regimen was administered or changed too
rapidly
The duration of therapy is too long
The dose was administered too rapidly
Compliance Compliance/Noncompliance Adherence/Non The patient does not understand the
Adherence Advice given
non availability of the drug complexity of
treatment
Undesirable side effects
Formulation not appropriate for patient
the patient prefers not to take the drug
The patient forgets to take the medicine
The medicine is too expensive
The patient cannot swallow or self-administer the
medication properly
Non accessibility of the medicines
Adopted and adapted from Strand et al (1998)
Please note that although the focus is on DTPs, the process allows for the
identification of disease related problems since the therapeutic approach is
verified and validated.
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EVALUATE PATIENT SPECIFIC MEDICAL INFORMATION AND
DEVELOP A CARE PLAN
STEP 4: Develop a care plan to resolve and or prevent drug therapy

problems
Prioritize Drug Therapy Problems
Once Step 1 is completed, DTPs are prioritized to facilitate the overall clinical
management of the patient
Identify desired therapeutic objectives and proposed actions
A statement expressing the pharmacist’s intention of what he wants to achieve

for the patient in relation to each DTP is made. This statement must be acceptable
to the patient and the health care team. These therapeutic objectives or goals are
expressed as measurable outcomes to be achieved within a defined time frame.
Note that it is vital that the pharmacist confirms the acceptability of the actions
to be taken with the patient and the healthcare team. Where there are a number of
options, the patient should be given sufficient information to select the most
appropriate option.
ENSURE THE PATIENT HAS ALL MEDICINATIONS AND MEDICAL

DEVICES, INFORMATION AND KNOWLEDGE NECESSARY TO
CARRY OUT DRUG THERAPY PLAN
STEP 5: The pharmacist providing Pharmaceutical Care assumes ultimate

responsibility for ensuring that his/her patient has been able to obtain, and is
appropriately using, any drugs and related products or equipment called for in
the drug therapy plan.
The pharmacist must also ensure that the patient has a thorough understanding
of the disease condition and the goals of therapy or medications prescribed in
the plan.
THE PHARMACIST REVIEWS AND MODIFIES THE PLAN
STEP 6: Develop a monitoring strategy
Identify relevant monitoring parameters for efficacy and toxicity to improve

patient therapeutic outcome
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STEP 7: Document Care Plan
The record of DTPs, goals of therapy, together with the proposed actions form a
documented pharmaceutical care plan. Very good documentation facilitates
continuity of care and clinical governance/audit
STEP 8: Implement Care Plan
The agreed pharmaceutical care plan is then implemented with the agreement of
the patient, in collaboration with other members of the health care team
STEP 9: Evaluate and review the Care Plan
Actual outcomes emerging from the monitoring strategy are evaluated in relation
to the therapeutic objectives to determine whether the DTPs have been resolved
or not. If not, then the care plan should be reviewed. The actual outcomes if
positive may be accepted as the best achievable for the patient, or an alternative
plan could be initiated. The plan is modified as the original DTPs are resolved or
new ones appear.
These nine steps should be followed through to provide optimum pharmaceutical

care to patients.
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STANDARD OPERATING PROCEDURES
These are Standard Operating Procedures (SOPs) to be followed in providing
clinical services to patients. They include assessment, development and
implementation of a pharmaceutical care plan, follow up, monitoring and
evaluation, discharge planning and counselling, multidisciplinary team activities;
and pharmacy-led care planning sessions
All pharmacists involved in providing pharmaceutical care for patients should

start as soon as the patient enters the facility so that he/she can support the
prescriber in the selection of medicines for patients
Particular attention should be given to patients, with newly diagnosed diseases,

chronic diseases like hypertension, diabetes, asthma, HIV, etc. to slow disease
progression through education and counselling to ensure adherence to therapy.
Patients on medications known to be associated with specific complications,
adverse events or narrow therapeutic index should also be targeted.
3.1 Assessment
Introduction
The purpose of assessment is to determine if the patients medicine related needs

are being met and if any actual or potential DTPs are present. This includes
collecting, analysing, and interpreting information about the patient, medical
condition, and medicine and medicines related therapies
Objective
The objective of assessment is to determine the patient’s medication needs by

obtaining information on the patient’s conditions, medications/ therapies, and
medical devices.
3.1.1 Collection of Patient-Specific Information/Data

Introduction
The need to collect, organize and integrate information on the patient, medicines
and disease are important. It enables one to identify patient’s medicine related
needs as well as medicine related problems. It is the first step to take in the
assessment of the patient
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Objective
To obtain relevant patient- specific information/data that may assist in overall

decision making regarding medicine therapy and patient care
Procedures
1) Establish the identity of the patient by OPD number, ward/ bed number,
gender, and age
2) Review the patient’s folder before making contact with the patient
3) Record all relevant information on the appropriate form according to the
instructions provided in this manual on how to complete each form
4) Establish rapport with patient (greet and Introduce yourself to the patient/
care giver)
5) Determine the ability of patient to communicate appropriately (cognition,
alertness, mental acuity, age, frailty, psychological state, social
circumstances); If patient is unable to communicate, contact caregiver
6) Explain the purpose of the interview
7) Respect the patient’s right to decline an interview
8) Maintain confidentiality, safety and rights of the patient once he/ she
accepts the interview. Minimize possibility of interruption and distraction
9) In the event that the patient is not involved in the administration and
management of his/her medicine, the interview should be continued with
the relevant person(s) e.g., relative or caregiver, after obtaining verbal
consent from patient, if possible
10) Employ good counselling skills
11) Collect patient specific data for the appropriate patient.
The following information should be obtained and reviewed:

a) Patient demography
b) Past medical history, is the patient hypertensive, diabetic, has a history
of thyroid disease, ever had surgery? etc.
c) Past medication history, including prescribed medicines, over the
counter (OTC) medicines, and herbal medicines history. Assess the
medication experience of the patient. Note whether the data collected
needs attention during the development of the care plan (medication
taking behaviour, understanding, concern, beliefs, etc.)
d) Immunization status where necessary
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e) History of ADRs, including medication allergy histories of past ADRs
f) Family history, is there a history of chronic ailments in the immediate
family that can genetically pre-dispose the patient?
g) Social and illicit drug use, alcohol and smoking history, and food or diet
preference or habit
h) Transfer/ referral letter from other institutions or any document that
shows the patient’s past medication history, such as the Medication
Information Record (Form 4)
i) Current diagnosis/ working impression
j) Relevant diagnostic parameters (laboratory tests, X-ray, ultrasound,
etc.)
k) Current medication use, including prescribed medicines, OTC
medicines and herbal medicines
Any other relevant information and the patient’s special needs
a) Summarize the important patient information

b) Ask the patient if he/she has any questions concerning his/her
medicines
c) Encourage the patient to provide further information, which may be
remembered later following the interview
d) Inform the patient that a pharmaceutical care plan will be developed
and when next a discussion with a pharmacist will take place.
3.1.2 Identification of drug therapy problems

Introduction
A Drug Therapy Problem (DTP) is any undesirable event experienced, or with a

potential to be experienced, by a patient, that involves, or is suspected to involve,
medicine therapy, and that interferes with the achievement of the desired goals of
therapy and requires professional judgement to resolve.
The identification of a DTP is the focus of the assessment made in this step of the
patient care process. Although DTP identification is technically part of the
assessment process, it represents a unique contribution made by pharmacists
providing pharmaceutical care
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Objective
To identify actual and potential DTPs
Procedure
1) Analyse the data that have been collected to assess whether the medicine
related needs of the patient have been met or not
a) Evaluate whether all of the patient’s medications are: appropriately
indicated; the most effective available; the safest possible; and if the
patient is able and willing to take the medication as intended to rule out
some medication problems
b) Evaluate the effectiveness, safety, and affordability of each medicine
c) Evaluate medication-taking behaviours and adherence to each
medication
d) With other members of the health care team, assess the appropriateness
of the current medications on the basis of health conditions, indications,
and the therapeutic goals of each medicine
2) Ensure the prescription (medicine order) is comprehensive and

unambiguous, that appropriate terminology is used, and that medicine
names are not abbreviated
3) Look for any non-formulary medicine orders outside the accepted

treatment guidelines, and document it.
4) Detect actual and potential DTPS affecting the patients’ needs. These
include:
• Medicines therapy with no indications
• Wrong drug prescribed for the condition
• Sub-optimal dose or over dose of medicines prescribed
• Adverse drug reaction
• History of medicine compliance and
• Untreated indication
5) For patients on the admission document any identified DTPs on the patient
Medication Profile Form (Form 1) and report any identified adverse drug
event (ADE) using the Adverse Drug Event Reporting Form in Annex A
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3.2 Development and Implementation of a Pharmaceutical Care Plan
Introduction
The care plan contains specific actions to achieve the pharmacotherapy needs and
also address drug therapy problems of a specific patient
Objective
To set goals according to the patient’s medical condition and to intervene at the
right time, if necessary
3.2.1 Goals of Therapy

Introduction
The goals of therapy are the ultimate result expected at the end of the therapeutic
period
Objective
To optimize the outcome of a patient’s medical condition within a given time

frame
Procedures
1) Identify the overall goals of therapy for an individual patient
2) Establish the goals of therapy for each indication of medicine therapy based
on clinical and laboratory parameters. Make realistic goals of therapy
appropriate to the patient’s present and potential capabilities, available
resources, and within an achievable time frame.
3) Discuss the goals of therapy with both the patient/caregiver and the
healthcare team
4) Based on the agreed goals of therapy, prepare a pharmaceutical care

plan(PCP) that addresses the medicine therapy needs and prioritized DTPs,
according to the patient’s disease condition, age, co-morbidity, renal and
liver functions, pregnancy status, etc. in collaboration with other health
care professionals to optimize the patient’s health outcomes.
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5) Communicate the plan effectively to the patient/caregiver and the
healthcare team
6) PCP should include follow up, monitoring and evaluation

components/activities
3.2.2 Intervention/Implementation
Introduction
Interventions are specific actions that are taken in accordance with the PCP to
resolve DTPs, to optimize the patient’s medication needs, and to prevent potential
DTPs in concert with the patient and the healthcare team.
Objective
To implement measures to resolve or prevent identified DTPs towards the

achievement of the goals of therapy for the patient’s medical condition
Procedures
1) Share the patient’s PCP with the health care team by involving the
healthcare team.
2) Reconcile the medications the patient has been taking with the ones about
to be ordered
3) Make the interventions to the drug therapy of specific patient based on the
individual patient characteristics, as stated in the goals of therapy
a) Interventions to resolve DTPs
b) Interventions to achieve the goals of therapy.
c) Interventions to prevent potential DTPs
4) Discuss the selection of appropriate and cost effective medicines for each
patient with the healthcare team based on updated Standard Treatment
Guidelines or the Hospital formulary.
5) Check whether the medicine order/prescription is written with legal

prescribing requirements and restrictions, and provide advice to the
prescriber on corrections, if necessary as per the policies of the institution/
nationa
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6) Discuss patient-specific recommendations with the prescriber i.e.
• changes in the dose, frequency, duration
• changing the drug therapy to a more effective and appropriate one
• stop an offending drug causing an ADR
7) Perform calculations for dosage adjustments, aid in the reconstitution for

parenteral preparations, and follow up on the stability after reconstitution
8) Provide key medication care information to the nurses taking care of the
patient, and encourage the nurses to report any ADEs identified
9) Provide patient education and counselling
10) Document the interventions made on the patient Medication Profile

Form (Form 1) and Medication Reconciliation Form (Form 3)
3.3 Follow Up
Introduction
In this step, the actual results and outcomes from medicine therapies are observed,
continually monitored, evaluated and documented
Objective
To continually re-evaluate and modify therapeutic goals with the changing patient
conditions and responses to therapy
Procedures
1) Ask the patient /caregiver about the patient’s health status or progress
2) Review the patient’s medical record in conjunction with the patient’s
clinical progress notes
3) Evaluate the patient’s outcomes, determine the patients progress toward
the achievement of the goals of therapy, determine whether any safety or
adherence issues are present, and assess whether any new DTPs have
developed or emerged.
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4) Take into account recent consultations, pathology results and
investigations, treatment plans, and daily progress when determining the
appropriateness of current medicine orders and when planning patient care.
5) Ensure that any medicine orders/prescriptions are written in accordance

with legal and local prescribing requirements and restrictions
6) Review all recent medicine orders and medication administration records.

The medicine orders may include routine medicine orders, variable dose
medicines (prn), intravenous therapies, single dose medicines, anaesthetic
and operative records, epidural medicine or other analgesics (i.e., all
records of medicines, fluids, or procedures affecting the patient, such as
diet/feeding orders)
7) After going through the checklist below, document the interventions,

treatment progress, and patient status on the patient progress note using
Form 2
Checklist for follow up:
1) Ensure the patient has access to all the medications ordered.
2) Ensure the medicine order is in accordance with patient’s previous

medicines, patient-specific considerations, e.g., disease state, pregnancy,
medicine dosage and dosage schedule, especially with respect to age, renal
function, liver function, dosage form and method of administration, and
medicine duplications
3) Check the medication administration record to ensure that all doses

ordered have been administered
4) Check to ensure whether administration times are appropriate, e.g., with

respect to food, other medicines, and procedures
5) Review whether infusion solution is used with regard to concentrations,

compatibles rate, and clinical targets, e.g. blood sugar levels, and blood
pressure. Check infusion rates and concentrations.
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6) Check and ensure that the medicine administration record clearly indicates
the date and time at which medicine administration is to commence
7) Check and ensure sure that the duration of administration of medicine is

appropriate. Specific consideration should be given to medications
commonly used in short courses, e.g. antibiotics, and analgesics
8) Check that the order is cancelled in all sections of the medications

administration record when medicine therapy is intended to cease or stop
9) Ensure that the detected actual or potential DTPs are resolved
10) Evaluate the adherence to the treatment being given
11) Evaluate the overall medication therapy management is being

implemented as planned
3.4 Monitoring and evaluation

Introduction
Ongoing Drug therapy must be continually monitored to ensure therapeutic

objectives are met. This ensures toxicity, sub-optimal doses and other drug
therapy problems that may emerge are prevented or resolved
Objectives:
To ensure set therapeutic objectives are being met.
Procedures:
1. Use appropriate subjective and objective parameters to monitor for

efficacy and toxicity.
2. Evaluate patient recovery based on progress report of the clinician
3. Make appropriate recommendations to continue or stop the therapy, or
initiate new treatment.
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3.5 Discharge Planning and Counselling for inpatients
Introduction
Discharge planning is the process by which the patient is assisted to develop a

self-management plan of care for ongoing maintenance and improvement of
health, even after he or she is discharged from the hospital. Discharge planning
usually involves notifying patients of their next scheduled OPD doctor’s
appointment and explaining medications to the patient.
Pharmacists should be actively involved in discharge planning and provide the

necessary medication information (verbal and written) i.e., the names of the
medicines, regimen, possible side effects, what do when doses are missed,
appropriate storage of medicines, when refills are needed, possible OTC
interactions, dietary and lifestyle advice etc.
Objectives
To ensure continuity of care through pharmacist involvement in decision making

about a patient’s discharge medication and provision of medication information
counselling
Procedures
1) Review the patient’s medical chart and medication forms used throughout
the care process for continuity of care.
2) Reconcile the medications the patient has been taking with the ones to be
ordered for discharge and record them on the Medication Reconciliation
Form (Form 3)
3) Work with the attending prescriber in the selection of discharge
medications
4) Check for any indications that may affect patient adherence and take
corrective actions
5) Complete the Medication Information Record (Form 4) and present it to
the patient or caregiver. Inform the patient or caregiver that he/she should
present the form when visiting healthcare providers in the future
6) Verbal information should be given to patients (and /or caregivers) about
their medicines
a) Provide verbal information to the patient or caregiver on the appropriate
use of the discharge medications
28
b) Give information about the medicines in a way that the patient/caregiver
can understand and before the patient is discharged
c) Check whether the patient has understood the information given and
provide answers/ explanations if he/she has questions
7) Encourage the patient or caregiver to seek information from the facility if
he/she encounters medicine-related problems, and advise who to contact if
he/she needs more information about the medicines, who will prescribe
continuing treatment, and how to access further supplies
8) Document the discharge medications and counselling provided to the
patient on the patient Medication Profile Form (Form 1) and update the
Pharmaceutical Care Progress Note Recording Sheet (Form 2)
3.5 Pharmacy Only Ward Rounds and Morning Sessions

Introduction
A pharmacy only ward round is a visit made by a group of pharmacists to hospital

inpatients to review and follow up their progress in achieving the goals of therapy.
Pharmacy only morning sessions (POMS) are organized to discuss selected
patient cases and to get updated information on patient management.
Pharmacy only ward rounds (POR) and morning sessions aim to facilitate better
patient care by ensuring appropriate medicine use wherein each pharmacist has a
key role and responsibility. The pharmacy team should decide the number of
rounds and morning sessions that should be conducted per week.
Objectives
• To exchange information on the pharmaco-therapeutic issues of patient

treatment
• To optimize therapeutic management by influencing medicine therapy
selection, implementation, monitoring, and follow up.
Procedures
3.5.1 Pharmacy Only Morning Session Activity
1) Conduct POMS in a scheduled manner
2) Select a challenging case suitable for discussion in pharmacy only

meetings
29
3) The POM should be conducted in a way that assures the sharing of
knowledge and experience
4) Prepare a comprehensive presentation that includes the patient history,

assessment, pharmacotherapy, DTP identified, and intervention
5) Focus the discussion on the current case intervention
6) Discuss the appropriateness of the current or alternate medication/doses

and nutritional changes
7) Interface with pharmacy staff regarding unusual medication

orders/prescriptions, patient issues, non- formulary needs
3.5.2 Pharmacy Only Ward Round Activities

1) Review medication history and access the current medication management
of all patients prior to the POR
2) Identify patients and cases to be discussed in the POR.
3) The pharmacist responsible should document the patient’s pharmaceutical

care issues to be discussed with the pharmacy
4) Present each case in the ward and discuss
a) List patient problems, medicine therapy, monitoring parameters,

therapeutic end-points, dosage, potential ADRs, and interactions.
b) Discuss the appropriateness of the current or alternate medications/doses

and nutritional changes
c) Relate issues regarding unusual medication orders/prescriptions, patient

issues, and non-formulary drugs to pharmacy staff
d) Perform medication dosage form conversion on medication that are

typically converted from intravenous to oral dosing, whenever possible, or
prior to patient discharge.
e) Identify conditions that need renal/ hepatic dosage optimization for

medications commonly used in inpatient care, depending on pertinent
laboratory results
30
3.5.3 After POM and POR
The pharmacist responsible should:
1) Communicate the recommendations to the health care team and implement

the decisions made by the team
2) The pharmacist responsible should consider all the outcomes of the round
and morning sessions to optimize the medicine therapy
3) Take important comments or suggestions from the participants to improve

subsequent sessions
4) Document and report all the results of the session on the pharmaceutical
care Interventions Daily Summary Form (Form 5)
3.6 Multidisciplinary Team Activities

3.6.1 Multidisciplinary Team Round
Introduction
The multidisciplinary team (MDT) round is conducted by health care providers

to share their contributions to cases and patient-specific issues. MDT facilitates
better patient treatment and appropriate medicine use wherein each health
professional plays his/her role and responsibility. As a member of the health care
team, the pharmacist should be actively involved in MDT activities
Objectives
• To provide patient-specific medicine information to health care

professionals at the time of medicine therapy decisions
• To optimize medicine treatment by influencing medicine therapy selection,
implementation, and monitoring and by involvement in medicine therapy
decisions
• To participate in discharge planning or other follow up activities
31
Procedure
1) Attend routine MDT ward rounds
2) Be proactively involved in the medicine therapy decision

a) Give suggestions for the selection and monitoring of medicines in
accordance with the patient’s condition
b) Contribute information about the patient’s medication and medicine
management
3) Review all medicine orders/prescriptions and correct incomplete and

invalid prescriptions immediately
4) Respond to any medicine information requests
5) Check for possible ADRs and medicine interactions for all prescribed
medicines
6) Participate in discharge planning or planning for ongoing care
7) Complete the necessary part of the pharmaceutical care Interventions Daily

Summary Form (Form 5)
3.6.2 Multidisciplinary Team Morning Session

Introduction
The MDT morning session is conducted by health care providers to discuss

patient-specific issues and decide on actions to be taken to optimize therapy. The
pharmacist should be actively involved in MDT morning sessions
Objectives
• To provide the team with detailed information on the medicines prescribed

for selected indications
• To optimize case-specific treatment by identifying DTPs in the case,
medicine selection, and provide medicine information with relevant
evidence
• To participate in discharge planning or other follow up on the selected case
32
Procedures
1) Routinely attend the MDT morning session

2) Be actively involved in the case selection and presentation in the MDT
morning session
3) Actively discuss the case with the team and provide the pharmacy service
contribution for the team
4) Identify any DTP observed for the presented case and resolve it by
providing rational information for the team on the prescribed medication
5) Be involved in the correct medicine selection for the case in the event of a
DTP and provide medicine information for the team on the prescribed
medication
6) Be involved in the discussion of patient follow up for the case presented
and discussed by the MDT and provide the medication information
necessary for patient follow up
7) Regularly update the team about the issues of medicine availability,
shortage, and expiry, and act as the pharmacist in charge as regards the
communication of hospital pharmacy service issues
8) Respond to any medicine information enquiries
9) Be involved in the discussion of discharge planning for the patient whose
case is presented and discussed by the MDT, and provide information
necessary for patient discharge
10) At the end of participation in MDT ward rounds and morning
session, the pharmacist in charge will perform the following:
a) Respond to medicine information enquiries
b) Discuss changes to medicine therapy with the patient and provide
counselling, where appropriate
c) Communicate changes in medicine therapy to other relevant staff
d) Make monitoring adjustments, as per the medicine therapy change
e) Complete the necessary documentation on the pharmaceutical care
Intervention Daily Summary Form (form5)
SOPs FOR DOCUMENTING AND REPORTING

PHARMACEUTICAL CARE
Introduction
33
Documentation is central to the provision of pharmaceutical care. As an integral
member of the health care team, the pharmacist must document the care provided.
Each step in the patient care process should be documented. Documentation is
vital to continuity of patients care
It demonstrates both the accountability of the pharmacist and gives value to the
pharmacist’s services. Failure to document pharmaceutical care activities and
patient outcomes can directly affect the quality of care provided to the patient.
If pharmacists are not communicating data/information routinely with other

providers, they may not be considered an essential and integral part of the health
care team. If you are not documenting the care you provide in a
comprehensive manner, then you do not have a practice.
This part of the manual has been developed to guide the documentation of
pharmaceutical care services at health facilities. The chapter contains
documentation and reporting formats and instructions on how to complete each
of the forms.
• patient Medication Profile Form (Form 1)

• Pharmaceutical Care Progress Recording Sheet (Form 2)
• Medication Reconciliation Form (Form 3)
• Medication Information Record (Form 4)
• Pharmaceutical Care Intervention Daily Summary Form (Form 5)
• Pharmaceutical care Intervention Monthly Summary and Reporting Form
(Form 6)
Pharmacists who are providing pharmaceutical care services are advised to follow
the instructions provided here closely when completing each documentation and
reporting form to ensure data quality.
Other members of the health care team (prescribers, nurses etc.) should be
encouraged to review and use the information recorded on the forms. Reports will
be collected by the Clinical Pharmacy Unit for monthly report compilation. These
reports will be reviewed by the heads of unit, aggregated quarterly and presented
to Management of the Hospital for record purposes.
Other stakeholders will access the reports for standardization purposes

nationwide through the Chief Pharmacist (Director of Pharmaceutical Services)
of the MOH and GHS yearly Senior Managers meeting as evidence of the benefits
34
of the Pharmaceutical Care Practice. The reports will provide valuable
information for decision makers at every level in identifying challenges, and to
design and implement appropriate strategies to further strengthen pharmaceutical
care
Objectives
• To standardize the provision of pharmaceutical care

• To ensure the availability of data about the service provided as evidence of
work done
General Instructions
• Please write neatly and legibly when entering information on all forms
• Deleting, erasing or whiting of entries is not encouraged. In case of
incorrect entry, cross out the word or phrase with one line, write the correct
word or phrase and put your initials or signature by the correction
• Follow the rows strictly when entering data to avoid mix-ups of
information
• Effort should be made to provide all information required. Spaces for data
input should not left blank
• File forms properly as described in the SOPs after recording of all
necessary data
• Forms should be available in adequate quantities in all units and wards at
all times
• Write in a size that fits the space provided
• Dates must be uniform and similar to the patient’s medical charts
• All forms are expected to be filled by the pharmacist providing
pharmaceutical care
4.1 Patient Medication Profile Form (Form 1)

Introduction
The patient Medication Profile Form is used to record basic patient, medical, and
medication information for all patients. The form can be printed or duplicated on
one page, front and back, and should be part of the Patient Medical Chart for each
patient. Each facility using these forms must have the identity of the Institution
35
or agency boldly printed on it before duplication. The teaching hospital may differ
in designations but GHS can use similar forms.
Access other patient information necessary to provide the service, such as vital
signs, laboratory results, and the like from the Patients Folder (medical and
Nursing Care Notes). Enter the date on which you start documenting the patients’
medication profile and record the necessary information under each section of the
form following the instructions provided below.
Purpose
The purpose of the patient Medication Profile Form is to be a source of medicine

related information for the provision of care to patients on a continuous basis,
from the OPD admission to discharge. The form contains socio-demographic,
clinical, medication, DTPs, care plan, and related information pertinent to the
provision of pharmaceutical care. Therefore:
• It should be used by the health care team as a source of medicine -related

information
• It will be helpful for follow up and prevention/ resolution of medicine
related problems, such as ADRs, drug-drug, and medication-disease
interactions, over and under dosing and adherence problems
When to Complete the Form
The patient Medication Profile Form should be completed starting from the
receipt of the prescription, admission of the patient until his/her discharge.
How to Complete the Form
The patient Medication Profile Form has six major sections, each of which is used
to record patient and medication-related information necessary for the provision
of care for the individual patients. The sections are:
• Patient Information
• Past Medical and Medication History
• Current Medications
• Drug Therapy Problems
• Recommendation/ Intervention
• Discharge Medication and Counselling
36
4.1.1 Patient Information
Fill in the following patient information in the spaces provided
• The patient’s name and card number should be recorded because it is

essential to identify the patient to whom the record belongs
• Demographic information, such as age, sex, weight, height, and body
surface area (BSA) especially for paediatric patients, and pregnancy status
(in weeks), should be recorded for the purpose of individualizing medicine
therapy (to determine the appropriate medication and dosage regimens for
treatment)
• The ward in which the patient is admitted, date of admission, and bed
number should be recorded
• Diagnosis must be recorded to offer a general overview of the patient’s
medical problems
Past Medical and Medication History
• Record the past medical history (information about past illnesses,

hospitalizations, surgical procedures, deliveries, accidents, or injuries) in
the space provided
• The patient’s medication history should be assessed and recorded in a very
organized manner. It should include a summary of all the events a patient
has had in his/her lifetime that involve medicine therapy, including
immunization status, social drug use, and history of relevant medication
use, along with his/her medication taking behaviour (adherence) since it is
shaped by the patient’s attitudes, beliefs, and preferences about medicine
therapy and determines a patient’s medication taking behaviour
• Capture allergies and/ or ADRs, describe that occurred reactions
specifically. We must introduce the concept of patients carrying allergy
cards especially for those with personal history of allergies. (Example)
• Record the immunization status of the patient.
Current Medications
• Write the active medical condition, illness, disease, signs, and/ or

symptoms being treated or being prevented by the use of medication under
the indication column
37
• Under the drug and dosage regimen column, record the drug product name,
dosage form, dose, and frequency of administration of each medication for
each indication that the patient is actually taking
• The date at which the patient started and stopped each medication should
be recorded
• Pharmacist’s Assessment (Drug Therapy Problem Identification) and

Care Plan
• This section is used to record the DTPs associated with each medical
diagnosis. Each medical diagnosis may have one or more DTPs associated
with it. A DTP can be resolved or prevented only when the cause of the
problem is clearly understood.
• Therefore, it is necessary to identify and categorize both the DTP and its
cause using the classification below as a reference. If the medicine therapy
is not in these categories, record it with an explanation, make sure to also
clearly indicate important laboratory results and other examination results
as evidence of the DTP identified
• Briefly state the care plan based on your assessment
• For each identified DTP, indicate the date and time when it was identified
and write your signature and initials
Recommendations/Interventions
Recommendations/ Interventions that are to be implemented should be recorded

appropriately and clearly. Interventions are designed to resolve DTPs, achieve
the stated goals of therapy, and prevent new DTPs from developing
• Recommendations / Interventions include initiating new medicine therapy,

or changing the product and / or dosage regimen. Additional interventions
to achieve the goals of therapy may include patient education, medication
compliance reminders/devices, referrals to other health care providers, or
monitoring equipment to measure outcome parameters
38
• The status of the recommendations/interventions made should be
documented as accepted or not. The practitioner’s initials and signature
that made the recommendations should be noted. If the intervention/
recommendations made was not accepted, mention clearly the reason why
it failed to be accepted
Discharge Medication and Counselling
• Be directly involved in the discharge planning, record the: date and time of
discharge; medication, including the name, dosage form, and dosage of all
discharge medications; and counselling and education provided to the
patient and caregiver
• Write your name and sign after you provide the discharge medication and
counselling to the patient
• The (Form 4) Medication Information Record is completed and given to
the patient to ensure continuity of care (Seamless Care)
39
‘
.;][ PATIENT MEDICATION PROFILE (FORM 1)
PATIENT DETAILS
Surname Forenames Weight (kg) Height (m)
Folder No Sex Age Community Pharmacist(Tel)
Address Social History
Initial Screening: Drug History Medical Notes Treatment Charts Initial U & Es Initial FBC Patient Interview
Signature:
PATIENT STAY
Date of Admission Referral Source Specialty
Pharmacist Medical Consultant Ward / Team
Presenting Complaints (Provisional) Diagnosis
Date Past Medical History Drug History Risk factors
Date Description of Medical or Date Medication used to treat problem or Comments

Pharmaceutical Problem causing problem
ADRs/ Sensitivities Relevant Non-Drug Treatment
INVESTIGATION INVESTIGATION
Na (135 - 150mmol/l Alb
K (3.5 - 5.5mmol/l) ALT
Urea (2 - 7mmol/l) Bili
Creat (53 - 120µmol/l) Alk Phos
Hb (11-16F G/dl), (14.5-18M G/dl) GGT
WBC (2.6-8.5*109/l)
Platlets (150-400*109)
40
[Type here]
Form 1: patient Medication Profile Form

(Follow the instructions when completing this form)
Patient Information Past Medical and Medication History

Name:______________________________ Medical history:
Folder No:________________
Sex:______ Age:__________
Wt:_________ Height:_______ Medication history and adherence:
Pregnancy status:__________________
Dept:______________________
Ward:______________________
Date of Admission:___________________ ADRs and/or Allergies:
Diagnosis:__________________________
Current Medications
Indication Drug and Dosage Regimen Start date Stop date
(Name, Dosage Form, Dose, Frequency)
41
4. Pharmacist’s Assessment and Care Plan
5. Recommendations/Interventions:
6.Discharge Medication and Counselling:
42
4.2 Pharmaceutical Care Progress Notes Recording Sheet
(Form 2)
Introduction
The Pharmaceutical Care Progress Notes Recording Sheet is used to record the
patient’s status and key interventions implemented from time to time to achieve
the goals of therapy stated for each patient. The progress note should be written
clearly and kept together with the Patient Medication Profile Form for each
patient
Purpose
The purpose of the Pharmaceutical Care Progress Note Recording Sheet is to

serve as an easy reference on the status of the patient and key interventions
implemented by the health care team at every visit.
The Pharmaceutical Care Progress Notes Recording Sheet should be completed

during each patient visit
1) Write the name of the patient and card number
2) Write the date and time each time you visit the patient
3) Use the explanation (N.B) and table 2 below to record the Current Status
4) The effectiveness and safety of the medications used should be

documented during every patient visit
5) Record the key interventions implemented
6) As soon as ADE are identified, they should be reported using the ADE
reporting Form and should be mentioned on the Patient Medication Profile
Form, whether they are reported or not
7) The pharmacist responsible for the care of the patient should write his/her
name and place his/her signature after preparing each and every progress
note
43
N.B: Current Status indicates the patient’s actual status at each visit. The
evaluation involves comparing the goals of therapy with the patient’s current
status. The terminologies describe the patient’s status, the medical conditions,
and the comparative evaluation of that status with the previously determined
therapeutic goals. The term also describes the actions taken as a result of the
follow-up evaluation
Table 2. Patient Status Category
Status Definitions
Resolved Therapeutic goals achieved for the acute condition, discontinue
therapy
Stable Therapeutic goals achieved, continue the same therapy for
chronic disease
Improved Progress is being made in achieving goals, continue the same
therapy because more time is required to assess full benefit
Partial Progress is being made, but minor adjustments in therapy are
Improvement required to fully achieve goals before next review
Unimproved Little or no progress has been made, but continue the same
therapy to allow additional time for benefit to be observed
Worsened A decline in health is observed despite an adequate duration
using the optimal medication: modify medicine therapy(
increase dose or add second agent with additive/synergistic
effects)
Failure Therapeutic goals have not been achieved despite an adequate
dose and duration of therapy; discontinue current
medication(s) and start new therapy
Expired The patient died while receiving medicine therapy; document
possible contributing factors, if they maybe medicine- related
44
SOPs for the Provision of Clinical Pharmacy Services in KBTH
Form 2: Pharmaceutical Care Progress Note Recording Sheet

Patient Name: _____________________________________ Folder No. ____________________________
45
4.3 Medication Reconciliation Form
(Form 3)
Introduction
Medication reconciliation is the standardized process of obtaining a patient’s best

possible history and comparing it to presentation, transfer, or discharge
medication orders/prescription in the context of the patient’s medication
management plan.
Medication reconciliation is a formal process intended to prevent medication

errors and medicine related problems at the transition points in patient care. It is
essential element of medication management and should occur at all points of
transition between episodes of care. Medication reconciliation also involves
documenting discrepancies identified between the medication history and current
medication orders/prescriptions and how these discrepancies were resolved
All patients should have their medications reconciled as soon as possible after
admission or presentation. If medication reconciliation cannot be completed for
all patients, prioritize patients most likely to obtain maximum benefit
Purpose
The purpose of medication reconciliation is to ensure that patients receive all

intended medicines and to avoid errors of transcription, omission, duplication of
therapy, and drug- drug, and medication-disease interactions.
When to Complete Form
The medication reconciliation process and completing the form should

commence as soon as possible on presentation or admission of a patient. A
documented, confirmed medicines list must be available before medicines are
prescribed (BNF, STG, MIH, KBTH formulary list). The form should be
completed during:
• Presentation or admission to the ward

• Transfer between wards and care settings within a hospital
• Discharge or transfer from the hospital to the community or other health
facilities
46
• The Medication Reconciliation Form is completed for each patient at each
service unit twice during his/her stay in the hospital, i.e., during admission
and at transfer or discharge
1) Write name of the hospital
2) Write the name, age sex and weight of the patient
3) Indicate the source (s) from where you obtained information about the
medication.
4) Record the medicine(s) to which the patient is known to be allergic (if any),
with a brief description of the reaction (if known).
5) For pre-admission medication, record the name, dose, frequency and

duration of administration of the medication(s) the patient has been taking
prior to admission. Get such information from the Medication Information
Record and/or the Medication Reconciliation Form, if the patient had been
discharged, transferred, or referred in the past, if such a record is not
available, get the information by asking the patient or caregiver.
6) Under the Reconciliation column, place a tick (√) under the appropriate
sub column regarding the decision on pre-admission medications made
during admission, i.e., whether to Continue (C) or Discontinue (DC) for
each medication. Record minor adjustments/ changes made on pre-
admission medications that are continued under the adjustments/changes
made column
7) Write the date, and put your signature and initials after entering the
information regarding the pre-admission medications
8) The list of medicines the patient is taking at discharge or transfer along

with the dose, frequency, and duration of use should be recorded under the
Current Medication rows
47
9) The plan for transfer or discharge regarding each of the medications the
patient is taking should be noted by ticking under the Continue (C) or
Discontinue (DC) column. Minor adjustments/ changes made on current
medications at transfer or discharge should be recorded under the
adjustments/ changes made column
10) Finally, write your name, put your signature, and record the date of
discharge or transfer
48
Form 3: Medication Reconciliation Form

Patient name: _______________________________________ Age ________ Sex _______ Weight __________
Source(s) of medication list ___________________________________________________________________
Allergies: __________________________________________________________________________________
Reconciliation
Plan on Plan on Plan on
Medication
admission transfer Discharge
Information Regimen (Drug name, Dose, Adjustments/
source Frequency, Duration) C DC C DC C DC Changes made
Pre-admission Medication
Current Medication
C – Continue, DC – Discontinue
Recorded by: Name ______________________________ Signature _______________ Date _______________
49
4.4 Medication Information Record
(Form 4)
Introduction
The Medication Information Record is used to provide written medication

information for patients leaving the facility in the case of referral, transfer, or
discharge. The Record is designed such that one sheet may be used to provide
medication information for two patients. The sheet should therefore be printed/
copied and cut into two pieces. It is very important that the responsible pharmacist
be part of the team during referral, transfer, or discharge planning so that he/she
is involved in the teams’ decision and may provide the necessary medication-
related information and advice for the patient
Purpose
The purpose of the Medication Information Record is to provide written

medication information for the patients leaving the facility in the case of referral,
transfer, or discharge to ensure continuity of care. The completed form is used as
a source of patient-specific medication-related information for the patient and
health care providers
The Medication Information Record should be completed at the time of referral,

transfer, or discharge of inpatients
When completing the Medication Information Record, the pharmacist should:
1) Write the name of the hospital and the date when the information was
provided
2) Write the name of the patient and the diagnosis (Dx)
3) List the medicine(s) to which the patient is allergic
50
4) Write all the medications the patient has been taking during his/her stay on
the ward/facility and those the patient will be using following referral,
transfer, or discharge, along with the start and stop date of each medication
5) Write the necessary information regarding the appropriate use of the

medications that the patient is taking (how to take, interactions, side
effects, ADRs, cautions) in the space provided under the table
6) Write the name and address of the hospital/caregiver to whom the patient
can communicate in case of any problems relating to his/her medications
7) Provide the Medication Information Form to the patient, along with verbal
advice about handling it safely, using it appropriately, and to show this
information record whenever he/she visits a health facility so that health
care professionals can easily access the past medical/medication history of
the patient
Remember: this form does not replace the verbal medication counselling
that should be provided to each patient
51
Form 4 Form 4
MEDICATION INFORMATION RECORD MEDICATION INFORMATION RECORD
Name of Hospital: ……………………………………Date: …….… Name of Hospital: ……………………………………Date:…….…
Patient Name: ………………………………………………………… Patient Name: …………………………………………………………
Dx: …………………………………………………………………… Dx: ……………………………………………………………………
Allergic to …………………………………………………………… Allergic to ……………………………………………………………
Drug & Dosage Regimen Start Date Stop Date Drug & Dosage Regimen Start Date Stop Date
(Name, Strength, Dosage Form, (Name, Strength, Dosage Form,
Dose, Frequency) Dose, Frequency)
52
53
Form 5: Clinical Pharmacy Interventions Daily Summary Form

Dept./ Ward: ……………………………………… Ward: ……………………………………………………
1. Daily direct patient care intervention summary
Intervention Follow-up Intervention

made documented
Folder Drug Therapy Problem Accepted (Y-Yes, Initial
Fully Partially Rejected (Y-Yes, N-
Date No Diagnosis Identified and the Cause Intervention Proposed N- No) No) & Sign
54
4.5 Pharmaceutical Care Interventions Daily Summary
(Form 5)
Introduction
The pharmaceutical care Interventions Daily Summary is used to summarize

pharmaceutical care activities carried out by a pharmacist on daily basis. The
form is used to record summarized information from inpatient care units. Each
pharmacist providing pharmaceutical care should complete the form on a daily
basis. The Pharmaceutical Care Interventions Daily Summary Form should be
printed on one sheet, front and back, made available in the office of the head of
pharmacy, and filed in a separate pharmaceutical care services documentation
cabinet
Purpose
The purpose of the Pharmaceutical Care Interventions Daily Summary is to

record summarized information on the pharmaceutical care activities that
assigned pharmacists are providing to patients on a daily basis in patient care
units. This record is also the basis for compiling information for regular reporting
and research purpose.
Each pharmaceutical care activity should be recorded on the day it is performed.

The information related to ward rounds and morning sessions should be filled in
on the summary form on the last work day of the week, adding up all sessions
attended and presentations made during that specific week
The form has two sections: daily direct patient care intervention summary, and
weekly morning session and round summary. Record the necessary information
on the form using the instructions below. Use Form 1 as a source of data when
completing this daily clinical activity summary form. One form may be used for
more than a day
55
4.5.1. Daily Direct Patient Care Interventions Summary
1) Record the ward details on top of the form
2) Record the date in the space provided, in case the form is used for more
than one day
3) Record patient ID
4) Record the patient diagnosis
5) Clearly write the DTP identified and its specific cause using the categories
listed in Table 1. Write a single DTP in each row; use another row for
additional DTPs, if any. You can record a description of the DTP and its
cause if you encounter a DTP that does not fit any of the categories given
6) Clearly and briefly record the interventions proposed to resolve the

identified DTP, achieve the goals of therapy, or prevent potential DTPs.
Write each intervention in each row; use another row for additional
interventions, if any
7) Tick (√) one of the three choices to indicate the status of acceptance of each
intervention proposed, whether it is fully accepted, partially, or rejected
Fully accepted: if all the recommendation(s) you made is/are accepted
Partially accepted: if some of the recommendation(s) you made is/are

accepted
Rejected: if the recommendation(s) is/are accepted at all
8)Put Y (Yes) if follow up has been made or N (No) if no follow up was done for
the patient in the follow-up Made column
9) Put Y (Yes) if pharmaceutical care provided is documented using relevant

documentation formats or N (No) if pharmaceutical care is not documented
at all
10) The initials and signature of the pharmaceutical care provider should be
made in the last column of each row, and for each case
56
4.5.2 Weekly MDT Rounds and POMS Morning Sessions Summary
• For the MDT and POMS activities listed in the column Description of
Activities, write the number of activities planned and those achieved on a
weekly basis
• Write the title/ topic of the cases actually presented for the MDT and
POMS morning sessions in the last column
• The name and signature of the person who compiled the data should be
placed in the space provided.
4.6 Pharmaceutical Care Interventions Monthly Summary and Reporting Form
(Form 6)
Introduction
The Pharmaceutical Care Interventions Monthly Summary and Reporting Form

is used to document and report the pharmaceutical Care activities of a specific
ward or hospital on a monthly basis. The source of information for the monthly
summary is the data collected on a daily basis using the Pharmaceutical
Interventions Daily Summary Form (Form 5). The summary data should be
reported to the Clinical Pharmacy Unit for to aggregated, analysed and to generate
information for decision making on pharmaceutical care services. The form
should be printed on one page and kept in the office of the Head of Clinical
Pharmacy Unit of Pharmacy in a separate cabinet for the documentation of
Pharmaceutical Care Services
Purpose
The Pharmaceutical Care Intervention Monthly Summary and Reporting Form is

a source of information on the pharmaceutical care activities undertaken in
specific wards, including the number of patients who have received
pharmaceutical care services, the DTPs identified, the interventions proposed and
implemented, in collaboration with other members of the health care team. The
information is useful for assessing the clinical and other economic impacts of
clinical pharmacy services and mobilizing more resources to further expand and
strengthen services.
57
Who Completes the Form?
The Pharmaceutical Care Interventions Monthly Summary and Reporting Form
should be completed by the pharmacists responsible for coordinating clinical
pharmacy and inpatient pharmacy activities in each ward, and the head of the
Clinical Pharmacy Unit. Each wards’ monthly forms should be prepared
separately and then aggregated and reported. The officer responsible for collating
all monthly reports from the satellite pharmacies will use these forms to generate
quarterly reports on pharmaceutical care practice in the health institutions.
When to complete the Form
The form should be completed at the end of each month so that data is captured
from the inpatient units where pharmaceutical care is provided.
Follow the instructions provided below when completing the Pharmaceutical

Care Interventions Monthly Summary and Reporting Form
1) Use the Pharmaceutical Care Interventions Daily Summary Form (Form 5)

and, if necessary, use the clinical pharmacy intervention documentation
forms (FORMS 1 & 2) as references to complete this form.
2) Use the Remarks column to note any relevant additional information

related to the data entered.
3) Write the reporting month and year.
4) Accurately record the total number of patients to whom Pharmaceutical

Care services were provided on your ward.
5) Write the total number of patients for whom the Medication Profile Form
was completed.
6) Under the Type and Number of DTPs identified, write the number of each
DTP identified according to the standard classification of DTPs. Use the
others (Specify) row to record any DTPs that might not fit any of the DTPs
listed, and specify the DTP and its cause in the space provided
58
Add up the DTPs and write the total number of DTPs identified in the total
row. For ADRs managed, indicate the number of ADRs reported to FDA
during the month in the Remarks column
7) Write the Type and number of interventions made to address the DTPs
identified, achieve the goals of therapy, and prevent potential DTPs. Add
them up and put the result in the Total Interventions Made space. Use the
others (specify) row to record interventions that might not fit the categories
given
8) Under Acceptance of Interventions, record the number of fully accepted,

partially accepted, and rejected interventions in the respective row for each
category
9) Under the Activities of the MDT, record the number of MDT morning
sessions and ward rounds attended by pharmacists, and the number of
cases/ topics presented by pharmacists in the MDT morning sessions.
Reports of pharmacists working in the same ward on MDT morning
sessions and ward rounds should not be totalled as they will be attending
the same sessions together
10) Under Pharmacy Only Activities, record the number of Pharmacy

Only Morning Sessions and Ward Rounds conducted, and the number of
cases / topics presented in the POMS
11) In the space provided, note any challenges encountered when using
the Pharmaceutical Care documentation, summary, and reporting forms,
and possible solutions
12) Write the number of pharmacists who were involved in the provision
of Pharmaceutical Care during the reporting period by classifying them
into qualified Clinical Pharmacists or Trained (pharmacists who are trained
to provide patient oriented services)
13) The report should be compiled by the head of the Clinical Pharmacy
Unit and submitted to the Director of Pharmacy for onward transmission
to the DTC and C.E.O on a monthly basis. Using a (√) indicate to whom
the report was sent
59
14) The pharmacists who compiled and approved the report should write
their names and signatures in the spaces provided and include the reporting
date.
60
Form 6: Pharmaceutical Care

Interventions Monthly Summary and
Reporting Form
Dept./ Ward: …………………………………… Month/Year:…………………………………
S/N Description Number Remarks
1 Total number of patients who received pharmaceutical care
Total number of patients with Inpatient Medication Profile forms
2 prepared
Type and number of drug therapy problems identified
Unnecessary drug therapy
Needs additional drug therapy
Ineffective drug
Dosage too low
Adverse drug reaction
Dosage too high
Noncompliance
Others(specify)
3 Total
Type and number of interventions made
Discontinued unnecessary drug therapy
Initiated additional drug therapy
Changed ineffective drug
Increased dosage
Adverse drug reactions managed
Decreased dosage
Improved compliance
Others (specify)
4 Total
Acceptance of Interventions
Accepted fully
Accepted partially
5 Rejected
Activities of the Multidisciplinary Team (MDT)
Number of MDT morning sessions attended
Number of cases presented by a pharmacist in the MDT morning
sessions
6 Number of MDT ward rounds attended
Pharmacy Only Activities
Number of pharmacy only sessions conducted
Number of cases presented at pharmacy only sessions conducted
7 Number of pharmacy only ward rounds conducted
Challenges in using the documentation and reporting forms (please indicate possible solutions):
_________________________________________________________________________________
_____________________________________________________________________
Number of pharmacists that provided clinical pharmacy services during this month:______________
Report sent to: • Clinical Pharmacy Unit • Hospital DTC • Hospital CEO
Report compiled by: Name _______________________Signature _________ Date ________
61
TYPES OF DRUG RELATED PROBLEMS
• P1 Adverse reactions P4. Drug Use Problem
• Side effect suffered (non-allergic) Drug not taken/administered at

all
• Side effect suffered (allergic) Wrong drug taken/administered
• Toxic effect suffered
P5. Interactions
• P2. Drug choice problem Potential interaction

• Inappropriate drug Manifest interaction
• Inappropriate drug form
• Inappropriate duplication of drug (group) P6. Others

• Contra-indication for drug Patient dissatisfied with therapy
• No clear indication for drug insufficient awareness of health
and disease
• No drug but clear indication Unclear complaints. Further clarification

necessary
Therapy failure (unknown reason)
• P3. Dosing problem

• Drug dose too low or regimen not frequent enough
• Drug dose too high or regimen too frequent
• Duration of treatment too short
• Duration of treatment too long
62
REFERENCES
1. American College of Clinical Pharmacy (2008). The definition of Clinical Pharmacy.

Pharmacotherapy, 2008; 28(6): 816
2. American Society of Health-System Pharmacists (2008). ASHP guidelines on
emergency medicine pharmacy services, Am J Health-Sys Pharm 2008; 68:81-85
3. Cipolle RJ, Strand LM, and Morley PC (2004). Pharmaceutical Care Practice : the
Clinician’s Guide, Second edition, New York; 2004
4. International Pharmaceutical Federation. FIP Statement of Professional Standards.
Medication errors associated with prescribed medications. Spain 1999
5. MOH, Ghana (The Chief Pharmacists’ Office); Standards for Pharmaceutical Care in
Public Health Institutions in Ghana.
6. PFSA and SIAPS. Standard Operating Procedures Manual for the Provision of Clinical
Pharmacy Services in Ethiopia, January 2015, Addis Ababa.
7. Pharmacotherapy (www.pharmacotherap.org)
8. SHPA Standards of Practice for Clinical Pharmacy, SHPA Committee of Specialty
Practice in Clinical Pharmacy. J Pharm Pract. Res. 2005; 35(2): 122-146
9. The American Journal of Pharmaceutical Education (www.ajpe.org)
10. The Consultant Pharmacist (www.ascp.com/publications/tcp/)
11. Tietze KJ (2012). Clinical skills for Pharmacists: A Patient-Focused Approach, 3rd
edition 2012
12. Wiedenmayer K, Summers RS, Mackie CA et al (2006). Developing Pharmacy
Practice: A focus on Patient Care, 2006 edition, WHO and FIP, 2006
63

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STANDARD OPERATING

PROCEDURES FOR THE

The Ashville Project & Medicare Modernization Act

As part of the efforts to advance and showpiece the practice of pharmaceutical

This manual, will contribute to the standardization of the provision of

It is expected that practicing pharmacists, pharmacy students, health system

C/Supt Pharm Ellen Sam- Specialist Clinical Pharmacist, Police Hospital

Pharm Dorcas Boateng- Specialist Clinical Pharmacist, Korle-Bu Teaching Hospital

Pharm Isaac Adupong- Communication Consultant, Blazing Impact Consult

Pharm Dr. Marc Dzradosi- Specialist Clinical Pharmacist, Central University

Pharm Dr Franklin Acheampong- Head of Research, Korle-Bu Teaching Hospital

Pharm Charles Agyeman Fordjour – Chairman, Strategic Planning committee

Pharm Cynthia Akumanue - Principal Pharmacist- Tamale Teaching Hospital

Pharm Kofi Boamah Mensah. - Komfo Anokye Teaching Hospital

Pharm Hamidu Abdulai- Director of Pharmacy Services, Tamale Teaching Hospital

Pharm Joseph Turkson- Cape coast Teaching Hospital

Pharm Bernard Agyei-Kwanin- Project Coordinator, SP

PROVISION OF PHARMACEUTICAL CARE

The philosophy of Pharmaceutical Care, which is defined by the International

According to the National Standards of Pharmaceutical Practice in Public Health

As Pharmacists, we are expected to:

• Support hospital and clinical managers with appropriate advice to enable

Objectives of the Manual

To standardize the provision of Pharmaceutical Care services with the aim of

• To Ensure that standardized Pharmaceutical Care services are provided in

• Step 1: Assess the patients medicine therapy needs and identify

• Step 3: Implement the care plan

• Step 4: Evaluate and review the care plan

1. A professional relationship must be developed with the patient/ the

Access needs and Identify

2 Develop a Care Plan

Implement the Care Plan

4 Monitor and Review the Care Plan

Develop or Identify the Pharmacotherapy Plan (CORE)

Identify the drug related problems or patient needs (PRIME)

Formulate a Pharmaceutical Care Plan

Communicate plan with Patient and Health Care Team

Document actions taken in Patient Medical Record

Adapted from American Hospital Association

C- Condition or patient need

ESTABLISH AND MAINTAIN A PROFESSIONAL RELATIONSHIP

STEP 1: Establish good communication with patient/ caregiver, and other

Talk to patient/caregivers, consult colleague health professionals and review

COLLECT, ORGANISE, RECORD AND MAINTAIN (CORM)

STEP 2: Pharmacists must collect and/or generate subjective and objective

It must be timely, accurate, and complete, and it must be organized and

Pharmacists must ensure confidentiality in the care of the patients

A DTP is any undesirable event experienced by a patient, which involves or is

PATIENT PROBLEM CAUSES

Adopted and adapted from Strand et al (1998)

STEP 4: Develop a care plan to resolve and or prevent drug therapy

Prioritize Drug Therapy Problems

Identify desired therapeutic objectives and proposed actions

A statement expressing the pharmacist’s intention of what he wants to achieve

ENSURE THE PATIENT HAS ALL MEDICINATIONS AND MEDICAL

STEP 5: The pharmacist providing Pharmaceutical Care assumes ultimate

THE PHARMACIST REVIEWS AND MODIFIES THE PLAN

STEP 6: Develop a monitoring strategy