The POMR is a general approach and helps to focus on the encounter, which

provides a structure for the documentation of the services provided. The following

section will describe the POMR and SOAP note in more detail.

Problem List

Problems are listed in order of importance and are supported by the subjective and

objective evidence gathered during the patient encounter. Each problem in the list can

then be given an identifying number. All subsequent references to a specific problem

can be identified or referenced by that number (e.g., “problem 1” or simply “1”).

These are generally thought of in terms of a diagnosed disease, but they also may be a

symptom complex that is being evaluated, a preventive measure (e.g., immunization,

contraception), or a cognitive problem (e.g., lack of adherence). Any condition that

requires a unique management plan should be identified as a problem to serve as a

reminder to the practitioner that treatment is needed for that problem. Different

settings and activities or clinical services will determine the priority of the problems

identified.

Medical problems can be drug related, including prescribing errors, dosing errors,

adverse drug effects, adherence issues, and the need for medication counseling.

Drug-related problems may be definite (i.e., there is no question that the problem

exists) or possible (i.e., further investigation is required to determine if the problem

really exists). The most commonly encountered types of drug-related problems are

listed in Table 1-5.

3,14

The distinction between medical problems and drug-related problems sometimes

is unclear, and overlap can exist. For example, a medical problem (i.e., a disease,

syndrome, symptom, or health condition) can be prevented, cured, alleviated, or

exacerbated by medications. When assessing drug therapy, several situations could

exist: treatment is appropriate and therapeutic outcomes have been achieved; drugs

that have been selected are ineffective or therapeutic outcomes are partially

achieved; dosages are subtherapeutic or medication is taken improperly; an

inappropriate drug for the medical condition being treated has been prescribed or is

being used; or the condition is not being treated.

Likewise, a drug-related problem can cause or aggravate a medical problem. Such

drug-related problems could include hypersensitivity reactions; idiosyncratic

reactions; toxic reactions secondary to excessive doses; adverse reactions (e.g.,

insulin-induced hypoglycemia or weight gain); drug–drug, drug–disease, drug–

laboratory test, and drug–lifestyle interactions; or polypharmacy, which may increase

the risk of adverse drug events.

22

Table 1-5

Drug-Related Problems

Drug Needed

Drug indicated but not prescribed; a medical problem has been diagnosed, but there is no indication that treatment

has been initiated (maybe it is not needed)

Correct drug prescribed but not taken (lack of adherence)

Wrong or Inappropriate Drug

No apparent medical problem justifying the use of the drug

Drug not indicated for the medical problem for which it has been prescribed

Medical problem no longer exists

Duplication of other therapy

Less expensive alternative available

Drug not covered by formulary

Failure to account for pregnancy status, age of patient, or other contraindications

Incorrect nonprescription medication self-prescribed by the patient

Recreational drug use

Wrong Dose

Prescribed dose too high (includes adjustments for renal and hepatic function, age, body size)

Correct prescribed dose but overuse by patient (overadherence)

Prescribed dose too low (includes adjustments for age, body size)

Correct prescribed dose but underuse by patient (underadherence)

Incorrect, inconvenient, or less-than-optimal dosing interval (consider use of sustained-release dosage forms)

Adverse Drug Reaction

Hypersensitivity reaction

Idiosyncratic reaction

Drug-induced disease

Drug-induced laboratory change

Drug Interaction

Drug–drug interaction

Drug–food interaction

Drug–laboratory test interaction

Drug–disease interaction

p. 7

p. 8

Subjective and Objective Data

Subjective and objective data in support of a problem are important because

assessment of patients and therapies requires the gathering of specific information to

verify that a problem continues to exist or that therapeutic objectives are being

achieved. Subjective data refer to information provided by the patient or another

person that cannot be confirmed independently. This is the data most commonly

obtained during a patient interview. Objective data refer to information observed or

measured by the practitioner (e.g., laboratory tests, blood pressure [BP]

measurements). Objective data are most commonly obtained from the EMR or paper

chart (data-rich environment). However, some objective data can be obtained in

data-poor environments. In the absence of a medical record, weight, height, pulse,

BP, blood glucose readings, and other objective information can be gathered during

the provider–patient encounter.

CASE 1-2

QUESTION 1: P.N., a 28-year-old man, has a BP of 140/100 mm Hg. What is the primary problem? What

subjective and objective data support the problem, and what additional subjective and objective data are not

provided but usually are needed to define this particular problem?

The primary problem is hypertension. No subjective data are given. The objective

data are the patient’s age, sex, and BP of 140/100 mm Hg. Each of these is important

in designing a patient-specific therapy plan. Because hypertension often is an

asymptomatic disease (see Chapter 9, Essential Hypertension), subjective complaints

such as headache, tiredness or anxiety, shortness of breath (SOB), chest pain, and

visual changes usually are absent. If long-term complications such as rupturing of

blood vessels in the eye, glomerular damage, or encephalopathy were present,

subjective complaints might be blurring or loss of vision, fatigue, or confusion.

Objective data would include a report by the physician on the findings of the chest

examination (abnormal heart or lung sounds if secondary HF has developed), an

ocular examination (e.g., presence of retinal hemorrhages), and laboratory data on

renal function (blood urea nitrogen, creatinine, or creatinine clearance). To place

these complications in better perspective, the rate of change should be stated. For

example, the serum creatinine has increased from a level of 1 mg/dL 6 months ago to

a value of 3 mg/dL today. Vague descriptions such as “eye changes” or “kidney

damage” are of little value, because progressive damage to these end organs results

from uncontrolled high BP, and disease progression needs to be monitored more

precisely.

CASE 1-3

QUESTION 1: D.L., a 36-year-old construction worker, tripped on a board at the construction site 2 days ago,

sustaining an abrasion of his left shin. He presents to the emergency department with pain, redness, and

swelling in the area of the injury. He is diagnosed as having cellulitis. What is the primary problem? What

subjective and objective data support the problem? What additional subjective and objective data are not

provided but usually are needed to define this particular problem?

The primary problem is cellulitis of the left leg. Useful pieces of subjective

information are D.L.’s description of how he injured his shin at a construction site

and his current complaints of pain, redness, and swelling. The fact that he was at a

construction site is indirect evidence of a possible dirty wound. Further information

must be obtained about how he cleaned the wound after the injury and whether he has

received a booster dose of tetanus toxoid within the past 10 years. Objectively, the

wound is on the left shin. No other objective data are given. Additional data to obtain

would be to document the intensity of the redness on a one-to-four-plus scale, the size

of the inflamed area as described by an area of demarcation, the circumference of his

left shin compared with his right shin, the presence or absence of pus and any

lymphatic involvement, his temperature, and a white blood cell count with

differential.

CASE 1-4

QUESTION 1: C.S., a 58-year-old woman, has had complaints of fatigue, ankle swelling, and SOB, especially

when lying down, for the past week. Physical examination shows distended neck veins, bilateral rales, an S3

gallop rhythm, and lower extremity edema. A chest radiograph shows an enlarged heart. She is diagnosed as

having HF and is being treated with furosemide and digoxin. What is/are the primary problem(s)? What

subjective and objective data support the problem(s)? What additional subjective and objective data are not

provided but usually are needed to define this (these) particular problem(s)?

The primary problem is systolic HF. Subjectively, C.S. claims to be experiencing

fatigue, ankle swelling, and SOB, especially when lying down. She claims to have

been taking furosemide and digoxin. An expanded description of these symptoms and

her medication use would be helpful. The findings on physical examination and the

enlarged heart on chest radiograph are objective data in support of the primary

problem of HF. In addition, other objective findings that would help in her

assessment would be the pulse rate, BP, serum creatinine, serum potassium

concentration, digoxin blood level, a more thorough description of the rales on lung

examination, extent of neck vein distension, and degree of leg edema. Pharmacy

records could be screened to determine current dosages and refill patterns of the

medications.

In this case, a second primary problem may be present. Current recommendations

for the management of HF include use of an angiotensin-converting enzyme (ACE)

inhibitor before or concurrent with digoxin therapy. Thus, a possible drug-related

problem is the inappropriate choice of drug therapy (“wrong drug”). The patient or

prescriber should be consulted to ascertain whether an ACE inhibitor has been used

previously, any contraindications exist, or possible adverse effects were

encountered.

Assessment

After the subjective and objective data have been gathered in support of specific

listed problems, the practitioner should assess the acuity, severity, and importance of

these problems. He or she should then identify all factors that could be causing or

contributing to the problem. The assessment of the severity and acuity is important

because the patient expects relief from the symptoms that are of particular concern at

this time. During the initial encounter with a patient, it might be discovered that the

medical problem is only a symptom complex and that a diagnosis is needed to more

accurately identify the problem and further define its severity.

The assessment is usually performed during or immediately after the data

gathering, while the provider keeps in mind evidence-based practices. For example,

if diabetes is assessed and pertinent subjective data (medication history, social

history, diet, exercise, etc.) and objective data exist (laboratory test results like

p. 8

p. 9

hemoglobin A1c

, low-density lipoprotein cholesterol [LDL-C], BP, etc.), then the

assessment of diabetes may be to determine whether the patient is meeting the goals

for the disease as defined by the ADA. If the patient is not at goal, then the

explanation of the reasons why would be described in the assessment, and the plan

would then be centered on helping that patient get to goal. Sometimes, the distinction

between subjective information provided by the patient and assessments made by the

practitioner are confused in the POMR. What the patient reveals belongs in the

subjective data, and how the provider interprets it belongs in the assessment. For

example, a patient stating that she is having difficulty affording her medications

belongs in the subjective information. However, a patient appearing to have costrelated lack of adherence belongs in the assessment, because it is the provider’s

interpretation of what the patient has stated.

DRUG THERAPY ASSESSMENT

A responsibility of the practitioner is to monitor the response of patients to

prescribed therapeutic regimens. The purpose of drug therapy monitoring is to

identify and solve drug-related problems and to ensure that all therapeutic objectives

are being achieved. Unless proven otherwise, the medical diagnosis should be

assumed to be correct. On occasion, the diagnosis may not be readily apparent, or a

drug-induced problem may have been diagnosed incorrectly as being a disease entity.

Health care practitioners share the responsibility to assess and monitor patient

drug therapy. For the pharmacist, medication reconciliation and the drug therapy

assessment may occur in many practice settings, including the community pharmacy

while dispensing or refilling prescriptions or counseling patients, during MTMS

encounters in the home or in the clinic, while assessing therapy for the hospitalized

patient, or as part of routine monthly evaluations of patients residing in long-term

care facilities. Many states have enacted legislation allowing pharmacists to develop

collaborative drug therapy agreements with physicians for disease state management

of common disorders such as asthma, diabetes, dyslipidemia, and hypertension.

Additional services commonly provided by pharmacists through collaborative drug

therapy agreements include anticoagulation monitoring, emergency contraception, and

immunizations.

5 These services often involve more detailed drug therapy evaluation

and assessment and may occur within or outside the traditional pharmacy setting.

Regardless, the patient’s need, time constraints, working environment, and

practitioner’s skill level govern the extent of monitoring. Similarly, the exact steps

used to monitor therapy and the order in which they are executed need to be adapted

to a practitioner’s personal style. Thus, the examples given in this chapter should be

used by the reader as a guide rather than as a recipe in a cookbook.

Plan

The next step in the problem-oriented (i.e., SOAP) approach is to create a plan,

which at the minimum should consist of a diagnostic plan and a MAP that includes

patient education. The plan is the action that was justified in the assessment. The plan

is clear and direct and does not require explanation (this should be explained in the

1.

2.

3.

4.

5.

assessment). For example, if a patient is experiencing constipation while taking an

opioid pain reliever, the plan would be to recommend a stool softener or stimulant

laxative such as docusate sodium. The plan should also include any follow-up that

would be necessary as a result of the action taken.

Patient Education

Educating patients to better understand their medical problem(s) and treatment is an

implied goal of all treatment plans. This process is categorized as the development of

a patient education plan. The level of teaching has to be tailored to the patient’s

needs, health literacy, willingness to learn, and general state of health and mind. The

patient should be taught the knowledge and skills needed to achieve and evaluate his

or her therapeutic outcome. An important component of the patient education plan

emphasizes the need for patients to follow prescribed treatment regimens.

The POMR will allow the provider to focus on the interview and encounter

independent of the site or service offered. The POMR facilitates documentation of

the provision of MTMS across multiple sites and services (across the continuum of

care).

The next few sections will discuss how to approach MTMS in various clinical

settings.

MEDICATION THERAPY MANAGEMENT

SERVICES IN THE COMMUNITY PHARMACY OR

AMBULATORY SETTING

The core elements of MTMS have been described by the American Pharmacists

Association (APhA) and the National Association of Chain Drug Stores (NACDS).

19

According to these organizations, the core elements of MTMS should include the

following components:

Medication therapy review (MTR)

Personal medication record (PMR)

Medication action plan (MAP)

Intervention or referral

Documentation and follow-up

Medication Therapy Review

The MTR may be a comprehensive review, including medication reconciliation, in

which the provider reviews all of the medications the patient is currently taking, or it

may be a focused review of one medication-related issue such as an adverse event.

Examples of services provided during the MTR are described in Table 1-6. MTR is

dependent on the information that is available from the patient or other data sources.

Table 1-6

Examples of Services Provided During a Medication Therapy Review

Assess the patient’s health status

Assess cultural issues, health literacy, language barriers, financialstatus, and insurance coverage or other

patient characteristics that may affect the patient’s ability to take medications appropriately

Interview the patient or caregiver to assess, identify, and resolve actual or potential adverse medication events,

therapeutic duplications, untreated conditions or diseases, medication adherence issues, and medication cost

considerations

Monitor medication therapy, including response to therapy, safety, and effectiveness

Monitor, interpret, and assess patient laboratory values, especially as they relate to medication use/misuse

Provide education and training on the appropriate use of medications

Communicate appropriate information to other health professionals, including the use and selection of

medication therapy

Source: American Pharmacists Association; National Association of Chain Drug Stores Foundation. Medication

therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm

Assoc (2003). 2008;48(3):341–353.

p. 9

p. 10

Figure 1-2 Example of a Personal Medication Record (PMR).

Personalized Medication Record

Regardless of the setting, a necessary tool to help with the gathering of the

medication information is the PMR. This medication record should be updated after

any change in medication therapy and should be shared with other health care

providers. The goal of this record is to promote self-care and ownership of the

medication regimen.

23 The PMR should be used at all levels of care, thereby

facilitating the medication reconciliation process required across the continuum of

care. An example of a PMR is shown in Figure 1-2.

Once the patient interview has occurred and the PMR has been updated, the

provider may still require information to make an assessment. In such cases, the

provider must do his or her best with the available information, or he or she may

obtain missing information such as the medical history or objective data from other

providers. In some encounters, obtaining the necessary information and medication

reconciliation may take the entire visit, necessitating a follow-up encounter.

Medication Action Plan

If adequate information is available to assess the current problem, a MAP should be

developed. Because the MAP is patient centered and is prioritized according to the

urgency of need, the provider and the patient should develop the plan together. An

example of a MAP can be seen in Figure 1-3.

Intervention and Referral

The MAP often describes the intervention performed in an MTM encounter and may

serve as documentation that can be shared with the patient and other health care

providers (like the PMR). The primary purpose of the MAP is to make the action

plan patient centered and to provide the patient with documentation of what they need

to do next in the action plan. It also provides space for the patient to document what

he or she did related to this action and when it was done. In some instances, the MAP

may involve referral to another provider (a physician or pharmacist with additional

qualifications) if the issue is beyond the scope of the intervening pharmacist.

Coordination of care is a key element of MTMS and MTR.

1 This may include

improving the communication between the patient and other health care providers,

enhancing the patient’s understanding of his or her health issues or concerns,

maximizing health insurance coverage, advocating on behalf of the patient to get

needed medications using available resources and programs, and various other

functions that will improve the patient’s understanding of his or her health care

environment and promote self-care. Coordination of care may be the primary action

taken on behalf of the patient and may be included in the MAP.

Documentation and Follow-up

The development of a documentation process is a necessary component of MTMS.

23

Documentation should be standardized and based on the POMR format. All

appropriate records, including the PMR and MAP, should be shared with other

providers to promote communication and continuity of care. If the encounter requires

follow-up, the documentation should reflect the timing of the follow-up care, and any

expectations of the patient and providers should be included. Thorough

documentation of the encounter allows all providers to quickly assess the progress of

the patient and determine that the desired outcome has been achieved.

An important aspect of documenting the encounter is to submit billing for the

encounter when appropriate. Although billing for MTMS is not universally accepted

by all payers, the introduction of the national provider identifier (NPI) and

pharmacist-specific

p. 10

p. 11

CPT codes may soon make this a reality.

4,24 The implementation of Medicare Part

D in 2006 allowed pharmacists in pharmacies contracted with prescription drug

plans to provide MTMS to plan-identified Medicare recipients. Pharmacists bill

these plans through the contracted pharmacy by using an NPI and one of three CPT

codes. The NPI number designates the provider to be paid, and the CPT determines

the amount of payment based on the services rendered. The CPT codes specific to

pharmacists providing MTMS include the following:

CPT 99605: Initial face-to-face assessment or intervention by a pharmacist with the

patient for 1 to 15 minutes

CPT 99606: Subsequent face-to-face assessment or intervention by a pharmacist

with the patient for 1 to 15 minutes

CPT 99607: Each additional 15 minutes spent face-to-face by a pharmacist with the

patient; used in addition to 99605 or 99606

Although the NPI number and CPT codes allow pharmacists to bill for MTMS, the

reimbursement varies by plan and negotiated contract and is beyond the scope of this

text. Pharmacists have also developed patient self-pay reimbursement strategies as

well as contracts with self-insured employers and state-run Medicaid programs to

provide services.

25,26

The Patient Protection and Affordable Care Act of 2010 and the Health Care and

Education Reconciliation Act of 2010 describe the need for payment reform that

promotes improved quality of care. Other providers also see these laws providing

new opportunities for pharmacists to participate in care teams such as the patientcentered medical home and pay-for-performance programs to improve medicationrelated care coordination, quality scores, and patient outcomes.

27,28 The enhanced

payment for improving quality in medication-related areas could be used to fund the

pharmacist in this activity.

CASE 1-5

QUESTION 1: M.C. is a 76-year-old woman who comes to an appointment at the community pharmacy with

her daughter for a focused MTR. She has a Medicare Part D prescription drug plan and is asking for help with

her medication costs. She indicates that she has type 2 diabetes, hypertension, back pain, and hyperlipidemia.

Her medications include lisinopril 40 mg once daily, metoprolol 50 mg twice daily, glipizide 5 mg once daily,

indomethacin 50 mg up to 3 times daily as needed for pain, and rosuvastatin 40 mg once daily. M.C. tells you

that she has trouble paying for her rosuvastatin (tier 3, $60 copayment) and would rather have something

generic that costs less (tier 1, $5 copayment). Further, she complains of muscle soreness and weakness during

the last 3 weeks.

What is the primary problem? What objective information can be obtained in a community pharmacy setting?

What additional information is necessary to determine the cause of her problem? How would a clinician assess

and document her problem(s) in a SOAP format?

Although the patient presented for a MTR, the primary complaint is the patient’s

self-reported muscle weakness and soreness during the last 3 weeks. Assuming that

M.C. is a patient of this pharmacy, the practitioner could gather the necessary

medication history from the PIS. Because the patient is present, this is a good

opportunity to develop a PMR with M.C. This process will help to quickly identify

any medication discrepancies between the pharmacy computer system and the

patient’s understanding of medication administration. If discrepancies are noted, the

practitioner can clarify them with M.C. right away as part of the intervention. The

PMR should also include a section to list medication allergies. The type of reaction

should also be included on the PMR so that other providers will know the severity of

the medication allergy (i.e., intolerance vs. anaphylactic reaction). Based on the data

gathered from the pharmacy computer and M.C., a PMR (depicted in Fig. 1-3) could

be developed.

Reviewing the medications alone often does not provide enough information to

determine whether M.C. is experiencing a medication-related event. Further

questioning related to the onset of her symptoms of muscle soreness and weakness

may help to determine whether this is a medication-related problem.

The practitioner can develop an assessment from this questioning and the PMR of

the current problem that she is experiencing. As indicated on the PMR, M.C. started

rosuvastatin most recently. The initiation of this medication corresponds to the onset

of her recent soreness and weakness. β-Hydroxy-β-methylglutaryl-CoA (HMG-CoA)

reductase inhibitors like rosuvastatin are known to cause myositis, or muscle

breakdown, which may lead to weakness and muscle soreness. Furthermore, the

prescribed dose is high for a woman of M.C.’s age. Based on this information, an

assessment of the problem can be pursued. If rosuvastatin is the suspected agent, the

plan would include actions necessary to solve the problem or to determine whether

rosuvastatin is the cause of her muscle soreness and weakness. Unfortunately, not all

of the necessary information is available (e.g., her baseline cholesterol, serum

creatinine, liver function tests, or creatine kinase levels) to develop a formal plan of

action to resolve the adverse medication event. However, part of the plan may be to

obtain the laboratory test results necessary to identify or act on the adverse

medication event. An example of the documentation of the SOAP note follows.

Primary Problem:

Muscle soreness and weakness (possible adverse medication event).

Subjective:

M.C. reports weakness and soreness, predominantly in her legs during the past 3

weeks. She has difficulty rising from her chair after sitting for long periods and

describes the pain as aching. The patient reports taking her medications as

prescribed and rarely misses a dose.

Objective:

Total cholesterol: 137 mg/dL; LDL-C: 56 mg/dL;

HDL: 54 mg/dL; Triglycerides: 136 mg/dL

Temperature: 98.5°F

Blood pressure: 144/68 mm Hg

Assessment:

M.C. has muscle weakness and soreness in her large muscle groups. According to

the American College of Cardiology and the American Heart Association M.C. is

considered to be at risk of heart disease because of her age and concurrent disease

states.

29 Her current lipid therapy is rosuvastatin 40 mg once daily, which was

started by her cardiologist 6 weeks ago. The initiation of rosuvastatin 40 mg

correlates to the timing of her muscle soreness and weakness. HMG-CoA

reductase inhibitors (i.e., rosuvastatin) are known to cause myositis or myalgias,

and this patient is at particular risk given her age, sex, and starting dose. It is

possible that the rosuvastatin could be causing her muscle soreness and weakness.

Other lipid-lowering agents could be tried or the dose of rosuvastatin could be

reduced, which might eliminate or reduce this adverse event. A creatine kinase

level should be obtained to determine the severity of the myositis. A serum

creatinine should also be measured, as myositis can lead to renal damage and

rhabdomyolysis in severe cases; however, this is usually accompanied by fever

and other symptoms that the patient is not currently experiencing.

Plan:

Drug-Related Adverse Event:

Discussed the possibility of an adverse medication event with the patient, which

included the signs and symptoms of myalgias and myositis.

p. 11

p. 12

Figure 1-3 Example of a Medication Action Plan (MAP).

Contacted Dr. Hart (M.C.’s cardiologist) to discuss the current problem with

rosuvastatin.

Per discussion with Dr. Hart, will obtain a creatine kinase level and serum

creatinine.

Discontinue rosuvastatin per the pharmacist’s recommendation. Dr. Hart agreed

that M.C. should temporarily stop her rosuvastatin until her laboratory values

are reviewed.

Alternative dosing of rosuvastatin 5 mg or another equivalent agent (atorvastatin

10 mg or simvastatin 20 mg) was discussed with Dr. Hart.