Standard Operating Procedures Manual for the Provision of

Clinical Pharmacy Services in Ethiopia

(First edition)

Pharmaceuticals Fund and Supply Agency (PFSA) in Collaboration with United

States Agency for International Development/Systems for Improved Access to
Pharmceuticals and Services (USAID/SIAPS)

October 2014

Addis Ababa
 TABLE OF CONTENTS

Page
FOREWORD...................................................................................................................................ii
ACKNOWLEDGMENTS………………………………………………………………………..iv
ACRONYMS……………………………………………………………………………………..vi
1. Introduction..................................................................................................................................1
1.1 Background........................................................................................................................1
1.2. Scope of the Manual..........................................................................................................2
1.3. Purpose of the Manual.......................................................................................................2
1.4. Objectives...........................................................................................................................3
2. SOPs for the Provision of Clinical Pharmacy Services for Inpatients........................................4
2.1. Assessment........................................................................................................................4
2.2. Development and implementation of a Pharmaceutical care plan....................................7
2.3 Follow up, monitoring and evaluation..............................................................................9
2.4 Discharge Planning and Counseling...............................................................................11
2.5 Multidisciplinary Team Activities..................................................................................12
2.6. Pharmacist-Led Care Planning Sessions.........................................................................14
3. SOPs for the Provision of Clinical Pharmacy Services for Chronic Outpatients......................16
3.1. Assessment......................................................................................................................16
3.2. Development and implementation of a Pharmaceutical care plan..................................18
3.3. Follow-up........................................................................................................................20
4. SOP for the Provision of Clinical Pharmacy Services for Emergency Patients........................21
5. SOPs for Documenting and Reporting Clinical Pharmacy Services.........................................22
5.1. In-Patient Medication Profile Form (Form 1).................................................................24
5.2. Pharmaceutical Care Progress Note Recording Form (Form 2).....................................31
5.3. Medication Reconciliation Form (Form 3).....................................................................34
5.4. Chronic Outpatients Medication Profile Form (Form 4)................................................37
5.5. Medication Information Record (Form 5)......................................................................42

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 5.6. Clinical Pharmacy Interventions Daily Summary Form (Form 6).................................45
5.7. Clinical Pharmacy Interventions Monthly Summary and Reporting Form (Form 7).....49

FOREWORD

The direct involvement of pharmacists in patient care (clinical pharmacy service) is a key
intervention to optimize outcomes of drug therapy thereby improving quality of patient care.
Pharmaceuticals Fund and Supply Agency (PFSA) has been collaborating efforts to implement
clinical pharmacy services in the Ethiopian health care system. As part of these efforts it was
found necessary and timely to prepare a guiding document to standardize clinical pharmacy
services provided by health facilities.

It gives me great pleasure to introduce the first edition of the Standard Operating Procedures
Manual for the provision of Clinical Pharmacy Services in Ethiopia to all beneficiaries().It is
believed that this manual will greatly contribute towards the standardization of the provision of
clinical pharmacy services in Ethiopia.

The Manual contains step-by-step procedures for the provision of clinical pharmacy services at
inpatient, chronic follow-up and emergency units along with the necessary documentation and
reporting Forms. After the draft was developed, the manual was reviewed and enriched by
experts from universities and hospitals that are actively involved in pharmacy education and
provision of the service, respectively. Health facilities should strive to set up the service as per
the guide given in this Manual. Pharmacists providing clinical pharmacy service are expected to
follow the SOPs strictly so as to ensure the provision of quality patient care. They are also
expected to document and report the services provided. Moreover, health system managers at
various levels should provide the necessary support and follow-up to ensure provision of the
service as per the SOPs. Moreover,

It is my belief that practicing pharmacists, pharmacy students, health system managers,

academicians, researchers and experts involved in education, mentoring and supportive
supervision of pharmaceutical services at health facility level will get this Manual useful. It will

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undoubtedly be helpful for service provision, management, education, research and monitoring
and evaluation purposes in relation to clinical pharmacy service.
I would like to take this opportunity to thank all members of the team and institutions for their
valuable contribution in the development of the Manual. I would also like to call the attention of
all concerned stakeholders to forward comments on the SOPs to the Agency through the
following addresses:
Mail: Pharmaceuticals Fund and Supply Agency (PFSA)
P.O.Box: 21904, Addis Ababa, Ethiopia
Telephone: +251118698556
Fax: +251112783931

Meskele Lera
Director General, Pharmaceuticals Fund and Supply Agency (PFSA)

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ACKNOWLEDGEMENTS

This SOPs Manual is developed with the technical and financial support of United States Agency
for International Development/Systems for Improved Access to Pharmaceuticals and Services
(USAID/SIAPS) Project. Pharmaceuticals Fund and Supply Agency (PFSA) would like to
acknowledge the technical and financial support of USAID/SIAPS Project.

The Agency would like to extend its appreciation for the following individuals who were
actively involved in the development of the SOPs Manual:
1. Biyansa Negera – PFSA (Pharmacist)
2. Haileyesus Wossen – PFSA (Pharmacist)
3. Kalkidan Endeshaw – PFSA (Pharmacist)
4. Mahlet Tibebu – PFSA (Pharmacist)
5. Robera Bogale – PFSA (Pharmacist)
6. Seblework T/Haimanot - PFSA (Pharmacist)
7. Siraj Adem - PFSA (Pharmacist)
8. Tayachew Shasho – PFSA (Pharmacist)
9. Tinsae Yigletu – PFSA (Pharmacist)
10. Fikru Worku - USAID/SIAPS-PFSA (Pharmacist)
11. Elias Geremew - USAID/SIAPS (Pharmacist)

We would also like to acknowledge the following individuals and organizations for actively
participating in the workshop that was organized to review the draft SOPs Manual.
1. Addisalem Geremew – ALERT Specialized Hospital (Patient-Oriented Pharmacist)
2. Addisu Getie – Debremarkos Referral Hospital (Pharmacist)
3. Elias Geremew - USAID/SIAPS (Pharmacist)
4. Fikru Worku - USAID/SIAPS-PFSA (Pharmacist)
5. Haftay Berhane – School of Pharmacy, Mekele University (Clinical Pharmacist)
6. Hyleyesus Wossen– PFSA (Pharmacist)
7. Kalkidan Endashaw- PFSA (Pharmacist)

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8. Mahilet Tibebu – PFSA (Pharmacist)
9. Mamo Feyissa – School of Pharmacy, Addis Ababa University (Clinical Pharmacist)
10. Minaleshewa Biruk – School of Pharmacy, Gondar University (Clinical Pharmacist)
11. Seada Abrar –Nigist Elleni Mohammed Memorial Hospital (Pharmacist)
12. Sileshi Tesfaye – Ambo Hospital (Pharmacist)
13. Tesfahun Chanie – School of Pharmacy, Jimma University (Clinical Pharmacist)

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ACRONYMS

ADR Adverse Drug Reaction

BSA Body Surface Area

CEO Chief Executive Officer

CCO Chief Clinical Officer

CPS Clinical Pharmacy Services

DTP Drug Therapy Problem

EHRIG Ethiopian Hospital Reform Implementation Guidelines

ESA Ethiopian Standards Authority

FMHACA Food, Medicine and Health Care Administration and Control Authority

FMOH Federal Ministry of Health

HPI History of Present Illness

MDT Multidisciplinary Team

OTC Over-the Counter

PFSA Pharmaceuticals Fund and Supply Agency

PMH Past Medical History

POMS Pharmacy Only Morning Sessions

POR Pharmacy Only Round

RHB Regional Health Bureau

ROS Review of Systems

SIAPS Systems for Improved Access to Pharmceuticals and Services

SOP Standard Operating Procedure

USAID United States Agency for International Development

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1. Introduction
1.1 Background
Clinical Pharmacy is a health science discipline in which pharmacists provide patient care that
optimizes medication therapy and promotes health, wellness, and disease prevention. The
practice of clinical pharmacy embraces the philosophy of pharmaceutical care, “pharmaceutical
care is the responsible provision of drug therapy for the purpose of achieving definite outcomes
that improve a patient’s quality of life”. Clinical pharmacy blends a caring orientation with
specialized therapeutic knowledge, experience, and judgment for the purpose of ensuring optimal
patient outcomes.

The Ethiopian Hospital Reform Implementation Guidelines (EHRIG) states that clinical
pharmacy services are patient-oriented services developed to promote the rational use of
medicines, and more specifically, to maximize therapeutic benefits (optimize treatment
outcomes), minimize risk, reduce cost, and support patient choice and decisions thereby ensuring
the safe, effective and economic use of drug treatment in individual patients. EHRIG expects
pharmacists to have the following functions:
 Provide advice to doctors, nurses and other health care workers on the clinical use of
medicines, economic drug utilization and safety,
 Offer direct patient care services through, for example, medication history-taking,
medicines education and advice, and
 Offer hospital managers, including clinical managers, appropriate advice and support to
enable them to make informed decision with respect to medicines policy, procedures and
guidelines designed to ensure safety, effectiveness and economy in medicine use.

As per the Minimum Standards for Hospitals (FMHACA/ESA) and EHRIG (FMOH) standards,
all hospitals are expected to provide clinical pharmacy services (CPS).

Over the past four decades there has been a trend for pharmacy practice to move away from its
original focus on medicine supply towards a more inclusive focus on patient care. The role of the

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pharmacist has evolved from that of a compounder and supplier of pharmaceutical products
towards that of a provider of services and information and ultimately that of a provider of patient
care. Increasingly, the pharmacist’s task is to ensure that a patient’s drug therapy is appropriately
indicated, the most effective available, the safest possible, and convenient for the patient. By
taking direct responsibility for individual patient’s medicine-related needs, pharmacists can make
a unique contribution to the outcome of drug therapy and to their patients’ quality of life.

Recognizing this, pharmacists have been trained in short-term clinical pharmacy in-service
training and Schools of Pharmacy in Ethiopia have changed their curriculum from product-
focused to patient- oriented with one year internship in addition to the inclusion of many clinical
courses. The first graduates of the new curriculum are deployed to almost all hospitals
throughout Ethiopia in 2013. As a result of this effort, many hospitals are currently providing
clinical pharmacy service which is a new development in the practice of pharmacy in the
country. But, the service is not being provided in a standardized and uniform manner. Therefore,
this standard operating procedures manual is developed in order to standardize and formalize the
provision of clinical pharmacy service in the country. SOPs on how to provide clinical pharmacy
service, document and report the service provided are addressed in this manual. In this SOPs
manual, the term ‘Clinical Pharmacy Service’ and ‘Pharmaceutical Care’ are used
interchangeably.

1.2. Scope of the Manual

This standard operating procedure (SOP) manual describes the specific steps to follow by
pharmacists providing clinical pharmacy services in Ethiopia. It contains SOPs for the provision
of clinical pharmacy services at inpatient, chronic outpatient and emergency units along with the
necessary documentation systems. The manual can be used by pharmacists working at health
facilities, health professionals involved in policy development, health service management,
supportive supervision, and mentoring of pharmaceutical services and those involved in
academic and research activities.

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1.3. Purpose of the Manual
This manual describes specific procedures on pharmaceutical care practice that will be used as a
hands-on reference on the appropriate execution of clinical pharmacy activities thereby it helps
to standardize the practice in all hospitals with the ultimate goal of optimizing patient care.

1.4. Objectives
General Objective

The general objective of these clinical pharmacy SOPs is to standardize the provision of clinical
pharmacy service thereby optimizing patient outcomes by ensuring rational use of medicines.

Specific Objectives

Specific objectives of the manual are the following:

 Ensure that good clinical pharmacy practice is provided in all places at all times.
 Clarify roles and responsibilities.
 Provide detailed account of how to perform clinical pharmacy activities.
 Serve as a source of guidance for new employees.
 Improve standards of clinical pharmacy service on continual basis.
 Provide evidence of commitment towards improving quality of patient care.

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2. SOPs for the Provision of Clinical Pharmacy Services for Inpatients
2.1. Assessment
Introduction

The purpose of the assessment is to determine if the patient's drug-related needs are being met
and if any actual or potential drug therapy problems are present. This includes collecting,
analyzing and interpreting information about the patient, the patient medical condition and the
patient drug therapies.

Objective

 The objective of assessment is to obtain information regarding patient conditions and

medications to give optimal pharmaceutical care.
I. Collection of patient specific information

Introduction

Collecting, organizing and integrating pertinent patient, drug and disease information are
important to identify the patients drug related needs and drug related problems which is the first
step in the assessment of the patient.

Objective

 To obtain relevant patient specific information that may assist in the overall decision
making of drug therapy and patient care.
Procedure

 Establish the identity of the patient.

 Determine the ability of the patient to communicate appropriately (cognition, alertness,
mental acuity, age, frailty, psychological state, social circumstances), if patient is unable to
communicate contact the care giver.
 Choose a suitable environment that allows privacy and confidentiality for the patient and
minimizes the risk of interruption and distraction.

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 Establish rapport with the patient/ care giver.
 Introduce yourself.
 Explain the purpose of the interview (other health professionals may have already performed
a medication history, so it may be necessary to explain the reason for a pharmacist-obtained
medication history).
 Respect the patient’s right to decline an interview.
 Adopt a physical position that allows the interview to take place comfortably and effectively.
 In the event that the patient is not involved in the administration and management of their
medicine the interview should be continued with the relevant person(s) e.g. relative or care
provider, after obtaining consent from the patient if possible.
 Employ an appropriate interview manner, e.g. avoid appearing rushed, be polite, attentive,
maintain eye contact, avoid interrupting the patient, be non-judgmental, and communicate
clearly and effectively.
 Collect patient-specific data; the following information should be sought and reviewed:
 Patient demographic data.
 Past medication (OTC, herbal medicines and prescription only drug use) history.
 Assess medication experience of the patient. Note whether the data collected
needs attention during care plan development (medication taking behavior,
understanding, concern, belief etc….).
 Past medical history.
 Current medication use.
 Current admission details as contained in the patient's medical record (chief
complaint and reason for current admission, assessment of the patient's clinical
problems, past and current medical or surgical problems, weight and height if
relevant, pregnancy status in women of childbearing age.
 Immunization status.
 ADRs including drug allergy histories and history of past ADRs.
 Relevant diagnostic parameters (laboratory tests, X-ray, ultrasound, etc).
 Family history, social and illicit drug use.
 Transfer/referral letter from other institutions.
 And other relevant information, special needs.

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  At the conclusion of collection of patient specific data :
 Summarize the important information of the patient.
 Describe expected plan for their medication management.
 Ask the patient if they have any questions concerning their medicines.
 encourage the patient to provide further information, which may be recalled after
the interview and
 Inform the patient when the next discussion with a pharmacist will be.
 document the obtained data
 Accurately document the data obtained on Inpatient Medication Profile Form
(Form 1) and
 Inpatient medication profile form should be attached in the patient medical chart.

II. Identification of drug therapy problems

Introduction

A drug therapy problem is any undesirable event experienced by a patient that involves, or is
suspected to involve, drug therapy, and that interferes with achieving the desired goals of therapy
and requires professional judgment to resolve. The identification of drug therapy problems is the
focus of the assessment and represents the key decisions made in the step of the patient care
process. Although drug therapy problem identification is technically part of the assessment
process, it represents the truly unique contribution made by pharmaceutical care practitioners.
Objective

 To identify actual and potential drug therapy problems.

Procedure

 Analyze the collected data for assessments of whether drug related needs of the patient
are met or not.
 Make sure that all the patient's medications are appropriately indicated, the most
effective available, the safest possible, and the patient is able and willing to take
the medication as intended.

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  Assess, with other members of the health care team, the appropriateness of current
medications on the basis of health conditions, indication, and the therapeutic goals
of each medication.
 Evaluate the effectiveness, safety, and affordability of each medication.
 Evaluate medication-taking behaviors and adherence to each medication.
 Ensure that the medicine order is comprehensive and unambiguous, that appropriate
terminology is used and that medicine names are not abbreviated.
 Look for any non-formulary medicine orders.
 Check the complete medication profile for duplications or contraindications.
 Detect medicine orders to which the patient may be allergic.
 Detect actual or potential medication interactions.
 Spot actual or potential drug related problems.
 Document any identified drug therapy problems on the Inpatient Medication Profile
Form (Form 1) and report identified ADRs to ADR focal person.

II.2. Development and implementation of a Pharmaceutical care plan

Introduction
The care plan outlines specific actions to achieve the pharmacotherapy need or drug therapy
needs and problem of specific patient.
Objective

 To set a goal according to the patient’s medical condition and to intervene if needed at
the right time.
I. Goal of therapy

Introduction

Goal of therapy is the ultimate result expected at the end of the therapeutic period.
Objective

 To optimize patient medical condition with in the given timeframe.

Procedure

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  Identify goal of therapy for individual patient.
 Establish goal of therapy for each indication of drug therapy based on clinical and
laboratory parameters.
 Negotiate goal of therapy mutually with the patient and other health care providers.
 Make a realistic goal of therapy to the patient’s present and potential capabilities,
available resources and within achievable time frame.
 Plan depending on the DTP identified.
 Prioritize drug therapy problems identified according to severity.
 Prepare therapeutic plan which addresses each of the patient’s disease condition, age, co-
morbidity, renal and liver function, pregnancy status etc... With other health care
professionals to optimize patient health outcome.
II. Intervention

Introduction

Interventions are specific action to resolve drug therapy problems, to optimize the patient
medication needs and to prevent new drug therapy problems.
Objective

 To develop and implement measures to resolve or prevent identified drug therapy

problems to achieve goal of therapy for the patient medical condition.
Procedure

 Reconcile the medications the patient has been taking with the ones about to be ordered.
 Participate in the selection of the appropriate and cost effective medicine for each patient.
 Make the intervention individualized to each patient as stated in the goal of therapy;
 Interventions to resolve drug therapy problems.
 Interventions to achieve goals of therapy.
 Interventions to prevent potential drug therapy problem.
 Discuss with the prescriber the need for medicine, and recommend a formulary
equivalent and alternative, if appropriate.
 Perform dosage adjustments, aid in reconstitution for parenteral preparations and follow
the stability after reconstitution.
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  Provide patient education and counseling.
 Document each activity performed in the Inpatient Medication Profile Form (Form 1)
and Medication Reconciliation Form (Form 3).

II.3. Follow up, monitoring and evaluation

Introduction

It is the step in which actual results and outcomes from drug therapies are observed, continually
monitored, evaluated, and documented.

Objective

 To continually re-evaluate and modify therapeutic goals with changing patient conditions
and responses to therapy.

Procedure

 Ask the progress of the patient from the patient/care giver.

 Review the patient's medical record in conjunction with the patient's clinical progress
note.
 Evaluate the patient's outcomes and determine the patient's progress toward the
achievement of the goals of therapy, determine whether any safety or adherence issues
are present, and assesses whether any new drug therapy problems have developed.
 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.
 Check that the medicine order is written in accordance with legal and local prescribing
requirements and restrictions.
 Review all recent medicine orders. These may include routine medicine orders, variable
dose drugs, intravenous therapy, single dose drugs, anesthetic 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).

9
 Ensure that the medicine order is comprehensive and unambiguous, that
appropriate terminology is used and that medicine names are not
abbreviated.
 Ensure that all necessary medicine is ordered and available.
 Ensure patients access to medications ordered.
 Ensure that the medicine order 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,
medication duplications.
 Check the medication administration record to ensure that all doses
ordered have been administered.
 Ensure that administration times are appropriate, e.g. with respect to food,
other medicines and procedures.
 Review infusion solution in regards to concentrations, compatibilities, rate
and clinical targets, e.g. blood sugar levels, blood pressure.
 Ensure that the medicine administration order clearly indicates the date
and time at which medicine administration is to commence.
 Ensure that the duration of administration of medicine is appropriate.
Specific consideration should be given to drugs commonly used in short
courses, e.g. antibiotics, analgesics.
 Detect the intervention made on actual or potential drug therapy is
resolved.
 Ensure that the order is cancelled in all sections of the medication
administration record when medicine therapy is intended to cease.
 Evaluate the adherence of the patient to the treatment being given.
 Monitor appropriate therapy is being implemented.
 Evaluate the care provided is based on the pharmaceutical care plan.
 Document the intervention on the patient progress note (Form 2)

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II.4. Discharge Planning and Counseling
Introduction

Discharge planning is the process by which the patient is assisted to develop a plan of care for
ongoing maintenance and improvement of health care, even after he or she may be discharged
from the hospital. Discharge planning usually involves notifying patients of their next physician's
appointment and explaining medication schedules. Pharmacists should actively involved in
discharge planning and provide the necessary medication information (verbal and written) to the
patient.
Objective

 To ensure continuity of care through pharmacist involvement in decision making about

patients discharge medication and provision of medication information counseling.

Procedure

 Review the patient’s medical and medication chart.

 Involve sufficiently together with the team during discharge decisions.
 Reconcile the medications the patient has been taking with the ones to be ordered during
discharge.
 Work with the attending physician in the selection of discharge medications.
 Check any signs of non-adherence and take corrective actions.
 Complete the “Medication Information Record” (Form 5) and provide to the patient or
care giver informing that he/she should present the form while visiting health care
providers in the future.
 Information should be given to Patients (and/or caregivers ) about their medicines and
have their expressed needs for information met;
o Provide verbal information to the patient or caregiver on the appropriate use of
discharge medications.
o Give information about their medicines in a form that they can understand before
discharge.

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  Encourage the patient or caregiver to seek information from the facility if he/she
encounters drug-related problems and advise who to contact if they need more
information about their medicines, who will prescribe continuing treatment and how to
access further supplies.
 Document the discharge medications and counseling provided to the patient on the
Inpatient Medication Profile Form (Form 1).

II.5. Multidisciplinary Team Activities

I. Multidisciplinary Team Round

Introduction

Multidisciplinary Team (MDT) round is conducted among health care providers to share their
contributions on the cases and patient specific issues. MDT primarily brings better patient
treatment and appropriate drug use where each health professionals play their role and
responsibility.

Objective

 To provide patient specific drug information to health care professionals at a time of drug
therapy decisions
 To optimize medicine treatment by influencing medicine therapy selection,
implementation and monitoring through involving in drug therapy decisions.
 To participate in discharge planning or other follow-up.
Procedure

 Attend routine Multidisciplinary Team (MDT) ward rounds.

 Proactively involve in drug therapy decision.
o Give suggestions for selecting and monitoring medicines in accordance with the
patient condition.
o Contribute information about the patients’ medication and medication
management.
 Immediately review all medicines order and correct incomplete and invalid prescription.

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  Respond to any medicine information enquiries.
 Detect ADRs and drug interactions of all prescribed medications.
 Participate in discharge planning or planning for ongoing care.
 Complete the necessary part of the Clinical Pharmacy Interventions Daily Summary
Form (Form 6).

II. Multidisciplinary Morning Session

Introduction

Morning session is conducted among health care providers to share their contributions on
patient-specific issues.

Objective

 To provide the team detail information on the drugs prescribed for selected case
 To optimize case specific treatment by identifying drug problems within the case, drug
selection and providing drug information.
 To participate in discharge planning or other follow-up on selected case.

Procedure

 Attend multi-disciplinary team (MDT) morning session routinely.

 Involve actively in the case selection and presentation on MDT morning session.
 Discuss on the case with the teams actively and provide the pharmacy service
contribution for the team.
 Identify drug therapy problem observed on the presented case and resolve it with
providing rational information especially for the prescriber.
 Involve in the correct drug selection for the case in DTP presence and provide drug
information for the team on the prescribed drugs.
 Involve in discussion of follow up of patient whose case is presented and discussed by
MDT and providing information necessary for the patient follow up.
 Regularly update the team about the issue of drug availability, shortage, expiry and act as
pharmacist in charge for communication of hospital pharmacy service issue

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  Respond to any medicine information enquiries
 Involve in discussion of discharge planning of patient whose case is presented and
discussed by MDT and providing information necessary for patient discharge.
 At the end of participation in interdisciplinary ward rounds and morning session the
pharmacist in charge will perform follow up:
 Respond to medicines information enquiries
 Discuss changes to medicine therapy with the patient and provide
counseling where appropriate
 Communicate changes in medicine therapy to other relevant staff
 Make monitoring adjustment as per the medicine therapy change
 Complete the necessary documentation on the Clinical Pharmacy
Interventions Daily Summary Form (Form 6)

II.6. Pharmacist-Led Care Planning Sessions

Introduction

Pharmacy only ward round is a visit made by a group of pharmacists to hospital inpatients to
review and follow their progress towards achieving the goal of therapy. Pharmacy only morning
sessions are organized to discuss on selected patient cases to get updated information on patient
management. Pharmacist only rounds and morning sessions aim to primarily bring better patient
care through ensuring appropriate drug use where each pharmacist has key role and
responsibility.
Objective

 To exchange information on pharmacology, pharmacokinetics and other aspects of drug

therapy.
 Optimize therapeutic management by influencing drug therapy selection, implementation,
monitoring, and follow up.

Procedure

I. Pharmacy only morning sessions (POMS) Activity

 Conduct POM on scheduled manner.

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  Select a case suitable for discussion in pharmacy only meetings.
 The POMS should be held in the way that can assure knowledge and experience share.
 Prepare comprehensive presentation that includes patient history, assessment,
pharmacotherapy, DTP identified and intervention.
 Concur the discussion with the current case intervention.
 Discuss appropriateness of current or alternate medication/ doses and nutritional changes.
 Interface with pharmacy staff regarding unusual medication orders, patients’ issues, and
non-formulary needs.

II. Pharmacy only round (POR) Activities

 Review medication history and assessment of current medication management of all
patients prior to the ward round.
 Consider the aspects of the patient’s medicine therapy likely to be discussed in PORs.
 Prepare the patients’ pharmaceutical care issues he/she wishes to raise with the team.
 Present each case in the ward and discuss:
 List patient problems, drug therapy, monitoring parameters,
therapeutic end- points, dosage, potential ADRs and interactions.
 Discuss appropriateness of current or alternate medication/ doses and
nutritional changes.
 Interface with pharmacy staff regarding unusual medication orders,
patients’ issues, and non-formulary needs.
 Perform medication dosage form conversion on medications that are
typically converted from intravenous to oral dosing whenever possible
or prior to patient discharge.
 Identify conditions that need renal/ hepatic dosing optimization for
medications commonly used in the inpatient care depending on
pertinent laboratory results.

III. After POM and PORs

 Intervene as per the decisions made in the sessions.

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  The case owner should take all the outcomes of the round and morning sessions to
optimize the drug therapy.
 Try to take any comment or suggestion from the participants so that you can improve the
next session.
 Document and report all the results of the session on the Clinical Pharmacy Interventions
Daily Summary Form (Form 6).

3. SOPs for the Provision of Clinical Pharmacy Services for Chronic

Outpatients
3.1. Assessment
Introduction

Assessment of current medication management is a review of all medicine orders to ensure safe
appropriate dosage administration, and to optimize medicine therapy and patient outcomes.

Objective

The objective of assessment is to obtain information regarding patient conditions and

medications to give optimal pharmaceutical care.

I. Collection of patient specific information

Introduction

Collecting, organizing and integrating pertinent patient, drug and disease information are
important to identify the patients drug related needs and drug related problems which is the first
step in the assessment of the patient.

Objective

To obtain data on patients’ status and medicine use that may assist in the overall care of the
patient.
Procedure

 Establish the identity of the patient

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  Introduce yourself.
 Incorporating physicians and other health professionals assessments, take and review
patient specific data:
o Identifying data: patient’s age, sex, lists the patient’s significant medical
problems, name of informant (patient, relatives).
o Chief complaint.
o History of present illness (HPI).
o Past medical history (PMH): Medications.
o Family history.
o Social history.
o Review of systems (ROS).
o Physical examination.
o Vital sign.
o Diagnostic parameters.
 Examine those patient-specific data; the following information should be sought and
reviewed:
 Current medication use.
 Immunization status.
 Drug sensitivities.
 Transfer/referral letter from other institutions.
 Ask the patient if they have any questions concerning their medicines.
 Encourage the patient to recall other relevant histories if any.
 Inform the patient when the next visit with a pharmacist will be.
 Accurately document the information obtained on the Chronic Outpatients Medication
Profile Form (Form 4).

II. Identification of drug therapy problems

Introduction

17
A drug therapy problem is any undesirable event experienced by a patient that involves, or is
suspected to involve, drug therapy, and that interferes with achieving the desired goals of therapy
and requires professional judgment to resolve. The identification of drug therapy problems is the
focus of the assessment and represents the key decisions made in the step of the patient care
process. Although drug therapy problem identification is technically part of the assessment
process, it represents the truly unique contribution made by pharmaceutical care practitioners.
Objective

To identify actual and potential drug therapy problems

Procedure

 Utilize past medication history, Current medication details and Referral letter.
 Ensure that the medicine order is comprehensive and unambiguous, that appropriate
terminology is used and that medicine names are not abbreviated.
 Look for any non-formulary medicine orders.
 Check patient’s own drugs brought into hospital.
 Check the complete medication profile for duplications or contraindications.
 Identify medicine orders to which the patient is/may be sensitive.
 Spot actual or potential drug related problems.
 Analyze the data obtained.
 Document any identified drug therapy problems (clearly categorizing according to the
seven drug therapy problems) on the Chronic Outpatients Medication Profile Form
(Form 4).

3.2. Development and implementation of a Pharmaceutical care plan

Introduction

The care plan outlines specific actions to achieve the drug therapy needs and problem of specific
patient.
Objective

18
To set a goal according to the patient’s medical condition and to intervene if needed at the right
time.

I. Goal of therapy

Introduction

It’s the ultimate result expected at the end of the therapeutic period.

Objective

To optimize, or relief the patient’s medical condition within a short period of time depending on
the medical condition of the patient.

Procedure

 Identify goal of therapy for individual patient.

 Establish goal of therapy for each indication of drug therapy.
 Establish goal of therapy based on clinical and laboratory parameters.
 Negotiate goal of therapy mutually with the patient and health care provider.
 Make a realistic goal of therapy to the patient’s present and potential capabilities,
available resources and within achievable time frame.
 Plan depending on the DTP identified.
 Prioritize drug therapy problems identified according to severity.
 Prepare therapeutic plan which addresses each of the patient’s disease condition, age,
co-morbidity, renal and liver function, pregnancy status etc. with other health care
professionals to optimize patient health outcome.

II. Intervention

Introduction

19
Interventions are specific action to resolve drug therapy problems, to optimize the patient
medication needs and to prevent new drug therapy problems.
Objective

To develop and implement measures to resolve or prevent identified drug therapy problems to
achieve goal of therapy for the patient medical condition.
Procedure

 Discuss with the prescriber the need for medicine, and recommend drug from the
formulary drug list.
 Check that the medicine order is written in accordance with legal and local prescribing
requirements and restrictions.
 Perform dosage adjustments.
 Manage actual or potential drug related problems.
 Endorse or annotate the medicine orders comprehensively with information such as
generic names, allergies and adverse drug reactions.
 Provide patient education and counseling.
 Document each activity performed Chronic Outpatients Medication Profile Form (Form
4).

3.3. Follow-up
Introduction

The follow-up evaluation is an essential step in the care process. It is the step in which actual
results and outcomes from drug therapies are observed, evaluated, and documented.
Objective

To continually re-evaluate and modify therapeutic goals with changing patient conditions and
responses to therapy.

Procedure

 Ask the progress of the patient/care provider.

 Review the patient's medical record.

20
  Check that the medicine order is written in accordance with legal and local prescribing
requirements and restrictions.
 Evaluate the adherence of the patient to the treatment being given.
 Check whether the goal of therapy previously set is achieved
 Document consultation and interventions made on the Chronic Outpatients Medication
Profile Form (Form 4).
 Complete the Medication Information Form (Form 4) and provide it to the patient by
informing that the patient should use the information included and show to health
professionals while visiting health facilities in the future.

4. SOP for the Provision of Clinical Pharmacy Services for Emergency Patients
Introduction

As part of emergency department team the patient oriented pharmacist is expected to provide
pharmaceutical care. Pharmacists should be involved in assuring appropriate prescribing and
administration, monitoring patient adherence to therapy, providing timely drug information
consultation to other health care providers, monitoring patient responses and laboratory values,
and providing patient education.
Objective

 To provide pharmaceutical care that optimizes safe and effective medication use in the
emergency department.
Procedure

 Provide direct patient care as part of the interdisciplinary emergency care team.
 Gather or review medical and medication histories and reconcile patients’ medications.
 Participate in the selection of medication in collaboration with emergency care team.
 Provide consultation on patient-specific medication;
o dose and dosage adjustments
o medication allergy assessment
o medication interaction
o adherent to national guidelines etc

21
  Provide timely drug information, and participation in formulary decision-making.
 Aid in reconstitution of parenteral preparations and follow stability after reconstitution.
 Assure timely and accurate administration of parenteral preparations.
 Monitor patient therapeutic responses (including diagnostic parameters).
 Monitor patient allergies and drug interactions.
 Continuously assess adverse drug reactions.
 Intervene on and report medication errors and ADEs.
 Educate patients/ caregivers about safe and effective medication use.
 Document the pharmaceutical care provided using the Inpatient Medication Profile Form
(Form 1)

5. SOPs for Documenting and Reporting Clinical Pharmacy Services

Introduction

Documentation is central to the provision of clinical pharmacy service. As an integral member of

the health care team, the pharmacist must document the care provided. Each step in the patient
care process must be documented. Such documentation is vital to a patient’s continuity of care
and demonstrates both the accountability of the pharmacist and give value of the pharmacist’s
services. Failure to document clinical pharmacy 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 healthcare 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 is, therefore, developed to guide the documentation of clinical pharmacy
services at health facilities. The document contains the following documentation and reporting
formats and guides on how to complete each of the forms.
 Inpatient Medication Profile Form
 Pharmaceutical Care Progress Recording Form
 Medication Reconciliation Form
 Chronic Outpatients Medication Profile Form

22
  Medication Information Record
 Clinical Pharmacy Intervention Daily Summary Form
 Clinical Pharmacy Intervention Monthly Summary and Reporting Form

Pharmacists who are providing clinical pharmacy service are highly advised to follow the guides
provided herein appropriately while completing each of the documentation and reporting forms
to ensure data quality. Other members of the health care team (Physicians, Health Officers, and
Nurses) should be encouraged to review and use the information recorded in the form.

Objectives

 To standardize the provision of clinical pharmacy service

 To ensure the availability of data about the service provided as an evidence

GENERAL INSTRUCTIONS

 When entering information into all forms, write neatly and legibly.
 Deleting, erasing, or whiting out of entries is not allowed. If wrong entries are made, cross
out the words or phrases with one line, write the correct word or phrase and put your initials
or signature.
 While entering data, follow the rows strictly to avoid mix-ups of information.
 All information required in a form should be completed. Do not leave empty any space
allocated for you to record data.
 After recording all the necessary data into a form, file it properly as described in the SOPs.
 Make sure that all forms are available in adequate quantities at your facility at all times.
 Write in a size that fits the space provided.
 Write all entries in English (not in Amharic).
 Dates must be uniform and similar to the one commonly used on the Patient’s Medical Chart.
Use Ethiopian Calendar with date/month/year format (e.g., 23/12/06) and always use
Calendar (having Ethiopian and Gregorian dates) as a reference to avoid error.
 All documentation forms are expected to be filled by the pharmacist providing clinical
pharmacy service.

23
5.1. In-Patient Medication Profile Form (Form 1)
Introduction

The In-Patient Medication Profile Form is used to record basic patient, medical and medication
information for admitted patients. The form should be printed back and front in one sheet and be
part of the Patient Medical Chart of each Patient. Print the hospital’s name on the form prior to
duplication. Access other patient information that is necessary to provide the service such as vital
signs, laboratory results and the likes from the Patient’s Medical Chart, diagnostic examination
order sheets and Prescription Paper. Write the date at which you started documenting the
patient’s medication profile and record the necessary information under each section of the form
following the instructions below.

Purpose

The purpose of the In-Patient Medication Profile Form is to serve as a source of drug-related
information for the provision of care for admitted patients on continuous basis from admission to
discharge. The form contains socio-demographic, clinical, medication, drug therapy problems,
care plan, and related information pertinent to provide pharmaceutical care. Therefore,

 It is to be used by the healthcare team as a source of drug-related information

 It will be helpful for the follow-up and prevention/resolution of drug-related problems
such as ADRs, drug-drug and drug-disease interactions, over- and under-dosing, and
adherence problems.

When to Fill Out the Form

The In-Patient Medication Profile Form should be filled out starting from admission of the
patient up to discharge.

How to Fill Out the Form

The In-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 individual
patients. These sections are:

 Patient Information

24
  Past Medical and Medication History
 Current Medications
 Drug Therapy Problems (Pharmacy Assessment)
 Recommendation/Intervention
 Discharge Medication and Counseling

I. Patient Information
Fill the following patient information in the space provided:
 The patient’s name and card number should be recorded as it is essential to identify the
patient to whom the record belongs.
 Demographic information like age, sex, weight, height and body surface area (BSA)
especially for pediatric patients should be recorded for the purpose of individualizing drug
therapy (to determine the appropriate drug 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.

II. Past medical and medication history

 Record the past medical history (information about past serious 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 the sum of all the events a patient has in his/her lifetime that
involve drug therapy including immunization status, social drug use and history of
relevant medication use along with the medication taking behavior (adherence) since it
shapes the patient's attitudes, beliefs, and preferences about drug therapy and principally
determine a patient's medication taking behavior.
 Document Allergies and or adverse drug reactions with specific description of the
reactions that occurred. Check whether the patient has Medicine allergy Identification
card and if the patient has allergy history and don’t have the card, make sure the patient
gets the Medicine allergy Identification card.

25
 III. Current medications
 Write the active medical condition, illness, disease, signs, and/or symptoms being treated
or being prevented by the use of medications under the indication column.
 Under the Drug & Dosage regimen’s 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 to each medication should be recorded.

IV. Pharmacist’s assessment (drug therapy problem identification)

 In this section is used to record the drug therapy problem(s) associated with each medical
diagnosis. Each medical diagnosis may have one or more drug therapy problems
associated with it. A drug therapy problem 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 drug therapy problem and its cause using the below classification as a
reference. If the drug therapy is not in these record with explanation. And make sure to
clearly indicate Important Laboratory results and other examination results as an
evidence of the DTP identified.
 For each identified DTP, indicate the Date and Time when it was identified and put your
signature and initials.

Table 1 Categories and Common Causes of Drug Therapy Problems

Assessment Drug Therapy Causes
Problem
 No valid medication indication for the drug at this time
 Multiple drug products are used when only single-drug therapy is
Unnecessary required
Drug Therapy  The condition is better treated with nondrug therapy
 Drug therapy is used to treat an avoidable ADR associated with
Indication another medication
 The medical problem is caused by drug abuse, alcohol use, or smoking
 A medical condition exists that requires initiation of new drug therapy
 Preventive therapy is needed to reduce the risk of developing a new
Needs condition
Additional Drug  A medical condition requires combination therapy to achieve
Therapy synergism or additive effects

26
  The drug is not the most effective one for treating the medical
Effectiveness condition
 The drug product is not effective for the medical condition
 The condition is refractory to the drug product being used
Ineffective Drug  The dosage form is inappropriate

 The dose is too low to give the desired outcome

 The dosage interval is too infrequent
Dosage too Low  The duration of therapy is too short
 A drug interaction reduces the amount of active drug available
 The drug product causes an undesirable reaction that is not dose-related
 A safer drug is needed because of patient risk factors
Adverse Drug  A drug interaction causes an undesirable reaction
Reaction  The regimen was administered or changed too rapidly
 The product causes an allergic reaction
 The drug is contraindicated because of patient risk factors
 The dose is too high for the patient
 The dosing frequency is too short.
Dosage too High  The duration of therapy is too long
Safety  A drug interaction causes a toxic reaction to the drug product.
 The dose was administered too rapidly
 The patient does not understand the instructions
 The patient prefers not to take the medication
Compliance/ Noncompliance  The patient forgets to take the medication
Adherence  Drug product is too expensive
 The patient cannot swallow or self-administer the medication properly
 The drug product is not available for the patient

V. Recommendations/interventions
Recommendations/Interventions that are to be implemented must be recorded appropriately
and clearly. Interventions are designed to resolve drug therapy problems, achieve the stated
goals of therapy and prevent new drug therapy problems from developing.
 Recommendations/Interventions include initiating new drug therapy, discontinuing
drug therapy, or changing the product and/or dosage regimen. Additional
interventions to achieve the goals of therapy can include patient education,
medication compliance reminders/devices, referrals to other health care providers,
or monitoring equipment to measure outcome parameters.
 The status of the recommendation /intervention made should be documented as
accepted or not. The practitioner’s initials and signature that made the

27
 recommendation should be stated. If the intervention/recommendation made don’t
accepted mention clearly the reason why it failed to be accepted.

VI. Discharge medication and counseling

 By directly involving in discharge planning, record the date and time of
discharge, medication including the name, dosage form and dosage of all
discharge medications and counseling and education provided to the patient or
caregiver.
 Then Put your name and signature after the discharge medication and counseling
you provided for the patient.
 Finally, it is very important to complete and provide Medication Information
Record (Form 5) to the patient to ensure continuity of care.

28
 Form 1:In-patient Medication Profile Form
(Follow the Instructional Guides while completing this form)

Name of Hospital: ____________________________________; Region: _______________

1. Patient Information 2. Past Medical and Medication History

Name: ___________________________________ Medical history:

Card #: ________________________

Sex: _______ Age: _______ Wt.: _____________ Medication history and adherence:

Height: _____________ BSA: ______________

Date of admission: ________________

Ward: __________ Bed No: ____________ ADRs and/or Allergies:

Diagnosis:

3. Current Medications

Indication Drug & Dosage Regimen Start Date and time Stop Date and
time
(Name, Dosage Form, Dose, Frequency)

4. Pharmacist’s Assessment

29
5. Recommendations/Interventions

6. Discharge Medication and Counseling

30
5.2. Pharmaceutical Care Progress Note Recording Form (Form 2)
Introduction

The Pharmaceutical Care Progress Note Recording Form is used to record the patient’s current
status from time to time in order to achieve the goal of therapy stated. The progress note should
be recorded clearly and kept together with the Patient Medication Profile Form for each patient.

Purpose

The purpose of the Pharmaceutical Care Progress Note Recording Form is to serve as an easy reference
on status of the patient for the healthcare team at every visit.

When to Fill Out the Form

The Pharmaceutical Care Progress Note Recording Form should be filled during each patient
visit.

How to Fill Out the Form

 Write name of the patient and card number.

 Write date and time each time you visit the patient
 Use the explanation and table below on how to record the “Current Status”.
 Effectiveness and safety of the medications encountered during every patient visit should
be documented.
 The pharmacist responsible for the care of the patient should write his/her name and put
signature after writing each and every progress note.
 As soon as ADRs are identified they should be reported using ADR reporting form
(Yellow form) and should be mentioned in the Patient Medication Profile Form whether
they are reported or not.

N.B. The Current Status indicates the patient’s actual status at each visit. Evaluation involves
comparing 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 terms also describe the actions taken as a result of
the follow-up evaluation.

Status Definitions
31
 Resolved Therapeutic goals achieved for the acute condition, discontinue therapy
Stable Therapeutic goals achieved, continue the same therapy for chronic disease
management
Improved Progress is being made in achieving goals, continue the same therapy
because more time is required to assess the full benefit of therapy
Partial Progress is being made, but minor adjustments in therapy are required to
improvement fully achieve the therapeutic goals before the next assessment
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 drug; modify drug therapy (e.g., increase the dose of the current
medication, add a second agent with additive or 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 drug therapy; document possible
contributing factors, if they may be drug related
Table 2: Patient status category

32
 Form 2: Pharmaceutical Care Progress Note Recording Form

Patient’s Name: ______________________ Card No. ___________________

33
5.3. 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 in the context of
the patient’s medication management plan. Medication Reconciliation is a formal process
intended to prevent medication errors and medicines-related problems at 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 and how
these discrepancies were resolved.
All patients should have their medication 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. This Form is prepared to be used for inpatients.

Purpose

The purpose of medication reconciliation is to ensure patients receive all intended medicines and
to avoid errors of transcription, omission, duplication of therapy, and drug-drug and drug-disease
interactions.

When to Fill Out the Form

The Medication Reconciliation process and filling the Form should commence as soon as
possible on presentation or admission and a documented, confirmed medicines list must be
available before medicines are prescribed. The Medication Reconciliation Form should be filled
during:
 Presentation or admission to a health facility
 Transfer between wards and care settings within the health facility
 Discharge or transfer from the health facility to the community or other health facilities
 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 transfer or discharge.

34
How to Fill Out the Form

 Write the name, age, sex and weight of the patient.

 Indicate the source (s) from where you obtained information about the medication.
 Record the drugs that patient is known to be allergic (if any) with brief description of the
reaction.
 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 Medication Information Record and/or the Medication
Reconciliation Form if patient had discharged transferred or referred in the past. If such
record is not available, get the information by asking the patient or care taker.
 Under the ‘Reconciliation’ column, tick under the appropriate sub column regarding the
decisions on pre-admission medications 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.
 Write date, and put your signature and initials after entering the information regarding the
pre-admission medications.
 The list of medicines the patient is taking during discharge or transfer along with dose,
frequency and duration of use should be recorded under the ‘Current Medication’ row.
 The plan during 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
during transfer or discharge. Minor adjustments/changes made on current medications
during transfer or discharge should be recorded under the adjustments/changes column.
 Finally, write your name, put your signature, and record the date of discharge or transfer.

35
 Form 3: Medication Reconciliation Form
____________________________________ Hospital
Patient’s name: ____________________________ Age ______ Sex _______Weight _____

Source(s) of medication list ___________________________________________________________

Allergic: _______________________________________________________________________

Medication Reconciliation
information Regimen (Drug name, Dose, Frequency, Plan on Plan on Plan on Adjustments/Changes
Source Duration) admission transfer Discharge made
C DC C DC C DC
Pre-admission Medication
Current Medication

C – Continue, DC - Discontinue

Recorded by: Name _____________________________ Signature ____________ Date ______________

36
5.4. Chronic Outpatients Medication Profile Form (Form 4)
Introduction

The Chronic Outpatients Medication Profile Form is used to record socio-demographic, clinical,
and medication information pertinent to specific outpatients who are on chronic follow-up to
ensure continuity of care while providing pharmaceutical care. The Form is to be prepared for
individual patient by printing back and front in one sheet.

Purpose

The purpose of the Chronic Outpatients Medication Profile Form is to serve as a source of drug-
related information for the provision of pharmaceutical care on continuous basis for outpatients
who are on chronic follow-up. Therefore,
 It is to be used by the healthcare team as a source of drug-related information
 It will be helpful for the follow-up and prevention/resolution of drug-related problems
such as ADRs, drug-drug and drug-disease interactions, over- and under-dosing, and
adherence problems.
When to Fill Out the Form

The Chronic Outpatients Medication Profile Form should be filled for each chronic outpatient
starting from the first day of visit throughout the period of follow-up in the facility.

How to Fill Out the Form

The Chronic Outpatients Medication Profile Form has four main sections; patient information,
clinical information, pharmacist’s assessment (drug therapy problem) and medication dispensing
information. Record the necessary information under each section of the form following the
instructions provided below.

I. Patient Information

Fill the following patient information in the space provided:

 Record patient’s name, card number, age, sex and weight on start.
 Record the date at which the patient started treatment.
 Under the address, record the telephone number of the patient and his/her support person

37
 II. Clinical information
 Record the type(s) of chronic disease(s).
 Record the History of allergies, if any, and specify the drug that is responsible for the
allergy along with the type of reaction the patient experienced.
 Record the past medical and medication history, and adherence (medication taking
behavior) of the patient.
 Other diseases that might co-exist with the chronic disease(s) and conditions like
pregnancy (record the months of pregnancy), lactation and any active drug or alcohol
abuse behavior should be recorded under the Concomitant Diseases/Conditions column.

III. Pharmacist’s Assessment (Drug Therapy Problems)

This is part of the Form where drug therapy problems (Assessment),
recommendations/interventions and patient’s current status are recorded during each follow-up.
 Record each DTP identified with its specific cause under the Assessment column using
Table 1 as a reference and write the date at which the DTP was identified under the Date
of follow-up column
 You can record description of the DTP and its cause if you come across a DTP that does
not fit with any of the DTP categories.
 Record recommendation and interventions that are to be implemented under the
Recommendations/ Interventions column. The drug name, dose, route, frequency, and
duration of therapy should be documented.
 In the last column, record “Patient Current Status”, i.e. status of the patient during each
visit (follow-up) using the Table 2 as a reference and indicate pertinent laboratory results,
and signs and symptoms.
 Put your signature and initials after recording DTPs, recommendations/interventions, and
patient current status on the last column.

38
IV. Medication Dispensing Information
 Record the date on which the medication/s was dispensed.
 Specify the reason why the patient visited the pharmacy. There are two possible reasons for
the patient to visit the dispensary in case of chronic care pharmacy service.
Start: - refers to patients for whom the medications for their chronic disease(s) or
concomitant disease are prescribed for the first time.
Refill: - refers to patients who are already on treatment and visiting the pharmacy to get
their subsequent doses.
 During each visit, record weight of the patient.
 Initials of the Physician who prescribed the medications should be recorded.
 For each drug prescribed, record the drug name (generic name and brand name), dose,
frequency, and duration/quantity dispensed. If more than 3 drugs are prescribed for a patient,
the information about the additional drug(s) can be recorded separately on the next row.
 Indicate for how many months the patient will use the medications he/she is taking under the
Number of Months column.
 List down the drugs (for concomitant disease) under the other drugs column if a patient is
taking medicines for diseases other than the major chronic disease(s).
 Record the date of the next visit, i.e. the last date at which the patient should come back to the
facility to collect the medications and beyond which the patient will run out of medicine.

Note: If the appointment date is determined by the clinician, the dispensing pharmacist should
use the same appointment date so that the patient can collect the medications on the same date
he or she visits the clinician. And the dispensing pharmacist should make sure that the
appointment date is made two or three days earlier than the date the patient takes his or her last
medicine. Hence, the patient collect the medicines earlier before the doses are finished which
avoid treatment interruptions.

 Finally, the dispensing Pharmacist should put his/her signature and initials in the last
column.

39
 Form 4: Chronic Outpatients Medication Profile Form
Name of Hospital: _________________________________________; Region: ____________________

1. Patient Information

Name: Card No.: Sex: Age: Wt. on start Date started:

Address:
Patient’s telephone: Support person’s telephone:
2. Clinical Information
Type/s of chronic disease:
History of Allergy:

Past medical history Past medication history and adherence Concomitant diseases/conditions

3. Pharmacist’s Assessment
Date of Assessment Recommendations/Interventions Patient Current status
follow-up (pertinent lab. results, and signs and symptoms)

4. Medicine Dispensing Information

40
 Reason Drug One Drug Two Drug Three Other drugs

Initials and Sig

Date
For visit Generic name (Brand name), Generic name (Brand name), Generic name (Brand name), (for concomitant

Prescriber’s

Dispenser’s
Number of

Next Visit
Dose, frequency Dose, frequency Dose, frequency diseases)

Months

Date of
Weight

Initials
Refill
and duration and duration and duration

41
5.5. Medication Information Record (Form 5)
Introduction

The Medication Information Record is used for providing written medication information for
patients’ leaving the facility in case of Refer, Transfer-out or Discharge. The Record is designed
in such a way that one sheet can be used for providing medication information for two patients. It
is very important that the responsible pharmacist should be part of the team during
discharge/transfer-out and refer planning so as to involve in the team’s decision and 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 patients’ leaving the facility in case of Refer, Transfer-out or Discharge to ensure the
continuity of care. The completed Form is used as a source of patient-specific medication-related
information for the patient and healthcare providers. The Form can be used for both inpatients
and chronic follow-up outpatients.

When to Fill Out the Form

The Medication Information Record should be filled during Refer, Transfer-out and Discharge
for both inpatients and chronic follow-up outpatients.

How to Fill Out the Form

In completing the Medication Information Record, the pharmacist should:

 Write Name of the hospital and the Date when the information issued.
 Write Name of the Patient and the Diagnosis.
 List down the medicine(s) to which the patient is allergic.
 Write all the medications the patient has been taking during his/her stay in the facility and
those the patient is using during the Refer/Transfer-out/Discharge along with the start and
stop date.
 Write the necessary information regarding the appropriate use of the medications that the
patient is taking (how to take, interactions, side effects, ADRs, caution...) in the space

42
 provided under the table.
 Write address of the Hospital/Care provider where/whom the patient can communicate in
case of any problems relating to his/her medications.

 Give the Refer/Transfer-out/Discharge Medication Information Form with verbal advice

about handling it safely, use 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 by no means can replace the verbal medication counseling that should be
provided to each patient.

43
 MEDICATION INFORMATION RECORD MEDICATION INFORMATION RECORD

Name of Hospital____________________ Date____________ Name of Hospital_____________________Date___________

Patient’s Name: __________________________________ Patient’s 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, Dose, (Name, Strength, Dosage Form, Dose,
Frequency) Frequency)

የመድሃኒት አጠቃቀም መረጃ: የመድሃኒት አጠቃቀም መረጃ:

በጤንነትዎላይምንምዓይነትእንግዳነገርካስተዋሉእናስለሚወስዷቸውመድሃኒቶችወይምስ
ለጤንነትዎማንኛውንምአይነትመረጃለማግኘትበስ.ቁ_________________
በመደወልወይምበአካልወደሆስፒታሉበመምጣትመገልገልየሚችሉመሆኑንበእክብሮትእን
ገልፃለን።
በጤንነትዎላይምንምዓይነትእንግዳነገርካስተዋሉእናስለሚወስዷቸውመድሃኒቶችወይምስ
ለጤንነትዎማንኛውንምአይነትመረጃለማግኘትበስ.ቁ_________________
በመደወልወይምበአካልወደሆስፒታሉበመምጣትመገልገልየሚችሉመሆኑንበእክብሮትእን
ገልፃለን።

44
5.6. Clinical Pharmacy Interventions Daily Summary Form (Form 6)
Introduction

Clinical Pharmacy Interventions Daily Summary Form is used to summarize clinical pharmacy
service activities carried out by a pharmacist on daily basis. The form is used to record
summarized information at inpatient as well as outpatient (chronic care pharmacy) level using
separate sheet for each. Each pharmacist providing such service should fill the form on daily
basis. The ‘Clinical Pharmacy Interventions Daily Summary Form’ should be printed back and
front in one sheet and made available in the office of the pharmacy head in a separate clinical
pharmacy service documentation cabinet.

Purpose

The purpose of the Clinical Pharmacy Interventions Daily Summary Form is to record
summarized information on the clinical pharmacy activities that assigned pharmacists are
providing to patients on daily basis at inpatient and chronic care pharmacy. The record is also the
basis for compiling information for regular reporting and research purpose.

When to Fill Out the Form

Each clinical pharmacy intervention should be recorded on the day it is performed. The
information related with ward rounds and morning sessions should be filled in the summary form
on the last working day of the week adding up all sessions attended and presentations made
during that specific week.

How to Fill Out the Form

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 following the
instructions below. Use the Medication Profile Form of patients’ as a source of data while
completing this daily clinical activity summary Form. One Form may be used for more than a
day.

45
 I. Daily direct patient care interventions summary
 Record name of the hospital and the ward on top of the form.
 Record the date in the provided space, if in case the form is used for more than a day.
 The card number should be specified (if the card numbers are coded for privacy use the
coded card numbers).
 Record the diagnosis of the patient on the diagnosis column
 Clearly write the DTP identified with its specific cause using the categories listed in Table
1. Write a single DTP in each row and use another row for additional DTPs, if any. You
can record description of the DTP and its cause if you come across a DTP that does not
fit with any of the above categories
 Clearly and briefly record the interventions made to resolve the identified DTP, achieve
the goal of therapy or prevent potential DTPs. Write each intervention in each row and
use another row for additional interventions made if any.
 Tick on one of the three choices to indicate the status of acceptance of each intervention
proposed/made whether they are fully accepted, partially accepted 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 not accepted at all.
 Put Y if follow up made or N if No follow up is done for the patient under the ‘follow-up
made’ column.
 Put Y if pharmaceutical care provided is documented using CPS documentation formats
or N if pharmaceutical care provided is not at all.
 Initial and signature of the clinical pharmacy service provider of each case should be
indicated under the last column of each row.
II. Weekly rounds and morning sessions summary
 Among the MDT and Pharmacy – Only activities listed in the column ‘Description of
Activities’, Write the number of activities planned and achieved in a weekly basis.
 Write the title/topic of actually presented cases on MDT and Pharmacy – Only morning
session in the last column.
 Finally, write the name and signature of the responsible person who compiled the data in
the space provided.
46
 Form 6: Clinical Pharmacy Interventions Daily Summary Form

Name of Hospital: _______________________________; Ward: ___________________

1) Daily Direct patient care intervention Summary
Date Card # Diagnosis Drug Therapy Problem Intervention Made Intervention Accepted Follow Initial

Intervention
documented
Identified and the cause Fully Partially Rejected -up &
Sign
made

47
2) Weekly Rounds and Morning Sessions’ Summary
Description of activity Number of sessions per week Specific topics presented

Planned Achieved

Morning Session
MDT

Seminar

Ward round

Morning
Session/Case
Pharmacy
only

presentation

Ward round

Reported by: Name _________________________________ Signature ____________________

48
5.7. Clinical Pharmacy Interventions Monthly Summary and Reporting Form
(Form 7)

Introduction

The Clinical Pharmacy Interventions Monthly Summary and Reporting Form is used for
documenting and reporting Clinical Pharmacy activities of a specific ward or hospital on
monthly basis. The source of information for the monthly summary is the one collected on daily
basis using the “Clinical Pharmacy Interventions Daily Summary Form”. The data should be
compiled on monthly and quarterly basis by specific ward and health facility using the daily
summarized information. The summary data should be reported to MOH/RHB, PFSA Branches
and SIAPS on regular basis (monthly and quarterly). The Form should be printed in a page of
one sheet and be kept in the office of the pharmacy head in a separate CPS’s documentation
cabinet.

Purpose

The Clinical Pharmacy Interventions Monthly Summary and Reporting Form serves as a source
of information on what clinical pharmacy activities are being undertaken at specific wards and
health facility including the number of patients who have got pharmaceutical care service, drug
therapy problems identified and interventions designed and implemented in collaboration with
other members of the healthcare team. The information is useful for assessing the clinical and
economic impacts of clinical pharmacy service and mobilizing more resources to further expand
and strengthen the service.

Who Fills Out the Form

The Clinical Pharmacy Interventions Monthly Summary and Reporting Form should be
completed by pharmacists responsible for coordinating clinical pharmacy and inpatient pharmacy
activities at each ward and chronic care pharmacy, clinical pharmacy service coordinator/Head
of Pharmacy Service of the hospital. Each ward’s or OPD’s Monthly CPS’s should be compiled
separately and then aggregated together and reported.
When to Fill Out the Form

The Form should be filled at the end of each month in such a way that data is captured at each
ward, chronic care pharmacy unit and facility level.

How to Fill Out the Form

Follow the instructions provided below while completing the Clinical Pharmacy Interventions
Monthly Summary and Reporting Form.
 Use the Clinical Pharmacy Interventions Daily Summary Form and if necessary use clinical
pharmacy intervention documentation forms as a reference to fill this form.
 Use the ‘Remark’ column to write any relevant additional information related with the data
entered.
 Write the reporting month and year, and reporting date.
 Record the data for inpatient and chronic care on the prepared separate columns.
 Accurately record the total number of patients to whom clinical pharmacy service was
provided in the hospital.
 Write the total number of patients served with documentation on the Patient Medication
Profile Form/Chronic Outpatients Medication Profile Form for inpatients and chronic follow-
up patients, respectively.
 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 DTPs
that might not fit to any of the DTPs listed and specify the DTP and its cause in the space
provided. Add up the DTPs and write the total number of DTPs identified on the total row.
For ADRs managed, indicate the number of ADRs reported to FMHACA during the month
under the ‘Remark’ Column.
 Write the type and number of interventions made to resolve the DTPs identified, achieve the
goal of therapy and prevent potential DTP’s and add and put the result as the total
Interventions made. Use the Others (Specify) row to record interventions that might not fit to
the categories given.
 Under the ‘Acceptance of Interventions’, record the number of fully accepted, partially
accepted and rejected interventions on the respective row for each.
 Under the ‘Activities within MDT’, record the number of MDT morning sessions and ward
rounds attended by pharmacists, and the number of cases/topics presented by pharmacists on
MDT morning sessions.
Note that, reports of pharmacists working in the same ward on MDT mornings and ward rounds
should not be summed-up as they will be attending the same sessions together.
 Under the ‘Pharmacy Only Activities’’, record the number of Pharmacy Only morning
sessions and ward rounds conducted, and the number of cases/topics presented on Pharmacy
Only Morning Sessions.
 Write down the challenges you encountered while using the clinical pharmacy service
documentation, summary and reporting forms and the possible way outs in the space
provided.
 Write the number of pharmacists who were involved in the provision of clinical pharmacy
services during the reporting period by classifying them into trained (pharmacists trained in
the 1 month clinical pharmacy training program) or graduated (pharmacists who are trained
according to the new patient-oriented undergraduate pharmacy curriculum).
 The report is expected to be compiled by head of the pharmacy section/representative and
sent to Hospital CEO/CCO, MOH or RHB, nearby PFSA Branch and USAID/SIAPS on
monthly basis (till the 5th day of the next month)
 Finally, the pharmacists who compiled and approved the report should write their names and
sign on the space provided.
Form 7: Clinical Pharmacy Interventions Monthly Summary and Reporting
Form
Name of Hospital: _____________________________ Month/Year: _________________

S/N Description Number Remarks

Inpatient Chronic
care
1 Total number of patients who got pharmaceutical care
2 Total number of patients with Patient medication profile form documented
3 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)
Total
4 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)
Total
5 Acceptance of interventions
Accepted Fully
Accepted partially
Rejected
6 Activities within a Multidisciplinary Team (MDT)
Number of MDT morning sessions attended
Number of cases presented by a pharmacist on MDT morning sessions
Number of MDT ward rounds attended
7 Pharmacy-only Activities
Number of Pharmacy only morning sessions conducted
Number of cases presented on Pharmacy only morning sessions conducted
Number of Pharmacy only round Conducted

Any challenge in using the documentation and reporting forms (if possible indicate the possible way
outs):________________________________________________________________________________
_____________________________________________________________________________________
Number of pharmacists that provided clinical pharmacy service during the reporting month:
Trained ___________ Graduated___________
Report sent to: □ MOH/RHB □ Hospital CEO/CCO □PFSA Branch □ USAID/SIAPS
Report compiled by: Name ______________________ Signature ________________
Report approved by: Name _____________________ Signature _________Date__________