The patient interview and record can be divided into sections with subjective and
objective data as well as an assessment and plan (including expected outcomes).
Components of subjective and objective data are the medical history, medication
history, and social history. In some situations, histories can be supplemented by the
generation of flowchart diagrams to monitor changes in specific variables with time.
These charts and documentation systems may be incorporated into the EHR, PIS, or a
A medical history is essential to the provision of MTMS. It can be as extensive as the
medical records that are maintained in an institution or physician’s office, or it can
be a simple patient profile that is maintained in a community pharmacy. The purpose
of the medical history is to identify significant past medical conditions or procedures;
identify, characterize, and assess current acute and chronic medical conditions and
symptoms; and gather all relevant health information that could influence drug
selection or dosing (e.g., function of major organs such as the gastrointestinal tract,
liver, and kidney; height and weight, including recent changes in either; age and sex;
pregnancy and lactation status; and special nutritional needs). Not all interviews
focused interview may be appropriate in settings in which the information required is
available electronically or is specific to a single disease state.
Patients usually can enumerate their medical problems in a general way, but the
practitioner often will have to probe more specifically to refine the diagnosis and
assess the severity of the condition. Diabetes mellitus is used to illustrate the types of
questions that can be used to gather important health information and assess drug
therapy. The following questions should generate information that will help to
determine whether P.J. has type 1 or type 2 diabetes.
How old were you when you were told you had diabetes?
Do any of your relatives have diabetes? What do you know of their diabetes?
Do you remember your symptoms? Please describe them to me.
What medications have you used to treat your diabetes?
When questions such as these are combined with knowledge of the
pathophysiology of diabetes, appreciation of the typical presenting signs and
symptoms of the disease, and understanding of the drugs generally used to treat both
forms of diabetes, meaningful MTM can be provided.
In the community pharmacy setting, patients generally present themselves in one of
four ways: (a) with a self-diagnosed condition for which nonprescription drug
therapy is sought, (b) with a newly diagnosed condition for which a drug has been
prescribed, (c) with a chronic condition that requires a refill of a previously
prescribed drug or the initiation of a new drug, or (d) upon referral from their health
plan or provider, or self-referral for focused medication therapy review (MTR).
In the first and second situations, the practitioner must confirm the diagnosis by
using disease-specific questions as illustrated in Question 1. In the third situation, the
practitioner uses the same type of questioning as in the first two situations; however,
this time the practitioner needs to evaluate whether the desired therapeutic outcomes
have been achieved. The practitioner must evaluate the information gleaned during
follow-up visits in the context of the history and incorporate it into his or her
assessment and medication action plan (MAP). In the fourth situation, in which
patients require a focused MTR, the medication and medical history information are
equally important. Without the medical history, it is not possible to evaluate whether
the drug therapy is appropriate, and without an accurate medication history, it is not
possible to determine whether the patient has reached the desired goals of therapy for
The goal of the medication history is to obtain and assess the following
information: the specific prescription and nonprescription drugs that the patient is
taking (such as OTC medications, botanicals, dietary supplements, recreational
drugs, alcohol, tobacco, and home remedies); the intended purpose or indications for
each of these medications; how it is taken (e.g., route, ingestion in relation to meals),
how much, and how often these medications are used; how long these agents have
been taken or used (start and stop dates); whether the patient believes that any of
these agents are providing therapeutic benefit; whether the patient is experiencing or
has experienced any adverse effects that could be caused by each of these agents
(idiosyncratic reactions, toxic effects, adverse effects); whether the patient has
stopped taking any of the medications for any reason; and allergic reactions or history
of hypersensitivity or other severe reactions to drugs. This information should be as
specific as possible, including a description of the reaction, the treatment, and the
A successful medication reconciliation process consists of a standardized
systematic approach, with the initial step in this process involving the collection of
the best medication history possible from every patient that enters any point in the
health care system. Although pharmacists are uniquely qualified and have
demonstrated increased accuracy in acquiring the medication history,
reconciliation requires a multidisciplinary effort in which all available resources are
integrated into each step of the process when appropriate.
using key members of the health care team such as nurses, pharmacy technicians,
pharmacists, and prescribers is essential in this process. Once an accurate
medication history is obtained, this information is used to ensure that as the patient
moves through the health care system, any deviation from prescribed regimen is
deliberate and based on acute changes in the patient’s condition. If an observed
discrepancy is the result of an intended therapeutic decision by the prescribing
clinician, appropriate documentation with either the reason for or intention to change,
hold, or discontinue the medication should be completed in a manner that is clear to
all members of the health care team. Unintentional variances in the medication lists
should be considered as potential medication errors pending clarification from the
Medication errors most commonly occur during transitions of care. It is essential
to conduct medication reconciliation when a patient is admitted to or discharged from
20,21 A crucial final step in the reconciliation process, and a vital
piece of MTMS, occurs at discharge to avoid therapeutic duplication, drug
interactions, and omissions of medications that may have been discontinued or placed
on hold during hospitalization. On departure from a health care facility, a complete
list of the patient’s medications must be communicated to the patient and the next
provider of service regardless of the setting. This process allows for informed
prescribing decisions and creates a safer environment for patients by improving the
accuracy of medication administration throughout the continuum of care.
Perhaps the most important aspect of the medication history is to ensure that no
assumptions related to medication use go unverified with the patient. The provider
should ask questions related to how the current medication therapy is actually taken
by the patient. The interviewer should then compare the use of medications as
defined by the patient to the prescription information on the prescription bottle or in
the PIS/EHR. This information may identify discrepancies or misunderstandings
between the prescriber and the patient. The patient may not have adequate health
literacy, and the interpretation of the medication instructions printed on the bottle or
described by a health professional may not be understandable to a patient. The
review of the medication history is an ideal time to identify and clarify such
might be asked to evaluate P.J.’s use of and response to insulin?
The following types of questions, when asked of P.J., should provide the
practitioner with information on P.J.’s understanding about the use of and response to
What type of insulin do you use?
How many units of insulin do you use?
When do you inject your insulin?
Where do you inject your insulin?
Please show me how you usually prepare your insulin for injection. (This allows the
patient to demonstrate a skill.)
What, if anything, keeps you from taking your insulin as prescribed?
ASSESSMENT OF THERAPEUTIC RESPONSE
How do you know your insulin is working?
What blood glucose levels are you aiming for?
What foods or meals do you find affect your blood sugar most?
How often and when do you test your blood glucose level?
Do you have any blood glucose readings that you could share with me?
Please show me how you test your blood glucose.
What is your understanding of the hemoglobin A1c blood test?
When was the last time you had this test done?
What were the results of the last hemoglobin A1c
Do you ever experience reactions from low blood glucose?
What symptoms warn you of such a reaction?
When do these typically occur during the day?
What circumstances seem to make them occur more frequently?
What do you do when you have low blood glucose?
The patient’s responses to these questions on drug use, therapeutic response, and
adverse effects will allow a quick assessment of the patient’s knowledge of
insulin and whether she is using it in a way that is likely to result in blood glucose
concentrations that are neither too high nor too low. The responses to these
questions should also provide the practitioner with insight about the extent to
which the patient has been involved in establishing and monitoring therapeutic
outcomes. Based on this information, the practitioner can begin to formulate the
The social history is used to determine the patient’s occupation and lifestyle;
important family relationships or other support systems; any particular circumstances
(e.g., a disability) or stresses in her life that could influence the MAP; and attitudes,
values, and feelings about health, illness, and treatments.
of P.J. to gain this information?
Describe your typical workday and a typical weekend day.
What type of prescription drug coverage do you have? How much do you pay for
your insulin and diabetic supplies? How often do you go without your insulin or
Describe your exercise habits. How often, how long, and when during the day do
you exercise? Describe how you change your meals or insulin when you exercise.
How many times per day do you usually eat? Describe your usual meal times.
What do you usually eat for each of your main meals and snacks?
Are you able to eat at the same time each day?
What do you do if a meal is delayed or missed?
Who cooks the meals at home? Does this person understand foods to prepare for
How often do you eat meals in a restaurant?
How do you order meals in a restaurant to maintain a proper diet for your diabetes?
(Note: This is asked to patients who frequently dine in restaurants.)
Who else lives with you? What do they know about diabetes? How do they respond
to the fact that you have diabetes? How do they help you with your diabetes
management? Does it ever strain your relationship? What are the issues that seem
to be most troublesome? (Note: These questions apply equally to the workplace
or school setting. Often, the biggest barrier to multiple daily injections is refusal
of the patient to inject insulin while at work or school.)
How do you feel about having diabetes?
What worries or bothers you most about having diabetes? (Note: Participate in the
patient’s care. This approach is likely to enhance the patient–provider
relationship, which should translate into improved care.)
APPROACH TO AND ASSESSMENT OF PATIENT
The provider–patient encounter will vary based on the location and type of services
provided and access to necessary information. However, the general approach to the
patient encounter should follow the problem-oriented medical record (POMR).
Organizing information according to medical problems (e.g., diseases) helps to break
down a complex situation (e.g., a patient with multiple medical problems requiring
multiple drugs) into its individual parts.
1,2 The medical community has long used a
POMR or SOAP note to record information in the medical record or chart by using a
standardized format (Table 1-4). Each medical problem is identified, listed
sequentially, and assigned a number. Subjective data and objective data in support of
each problem are delineated, an assessment is made, and a plan of action identified.
The first letter of the four key words (subjective, objective, assessment, and plan)
serves as the basis for the SOAP acronym.
Elements of the Problem-Oriented Medical Record
Under each problem name, the following information is identified:
concerning symptoms, previous treatments, medications used, and adverse effects encountered.
These are considered nonreproducible data because the information is based on the patient’s
interpretation and recall of past events.
pharmacy patient profile information. Objective data are measurable and reproducible.
supported logically by the above subjective and objective data. The assessment should not include a
problem or diagnosis that is not defined above.
Plan A detailed description of recommended or intended further workup (laboratory tests, radiology,
consultation), treatment (e.g., continued observation, physiotherapy, diet, medications, surgery),
patient education (self-care, goals of therapy, medication use, and monitoring), monitoring, and
follow-up relative to the above assessment.
Sometimes referred to as the SOAP (subjective, objective, assessment, plan) note.
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