A Method of Documenting Pharmaceutical Care Utilizing Pharmaceutical Diagnosis

This paper proposes an outline for writing-up a patient case that can be used by experienced pharmacy practitioners, or by students during case-study courses or clerkship training. When such written documentation is placed in the patient’s primary medical record it not only communicates pharmacotherapeutic evaluations and treatment recommendations but also serves as a record of pharmaceutical care. The wellknown SOAP outline, even in an expanded format, is not satisfactory for pharmacy because it uses clinical information to characterize medical diagnoses rather than drug-related problems. The key element of the write-up is pharmaceutical diagnoses. Pharmaceutical diagnoses define the nature of specific drug-related problems. Each diagnosis serves as a foundation for desired outcomes, treatments, monitoring parameters, and subjects for patient counseling and education.