• Organisasi Kesehatan Dunia (WHO) melaporkan

Asuhan Kefarmasian
Penyakit Jantung Koroner:
Sindrom Koroner Akut
satu dari tiga orang di seluruh dunia pada tahun
2001, meninggal karena penyakit kardiovaskular.
• Di Indonesia dilaporkan Penyakit Jantung Koroner
(yang dikelompokkan menjadi penyakit sistem
sirkulasi) merupakan penyebab utama dan
pertama dari seluruh kematian, yakni sebesar
26,4%, angka ini empat kali lebih tinggi dari angka
kematian yang disebabkan oleh kanker (6%).

1 2
• Perkembangan terkini memperlihatkan,
penyakit kardiovaskular telah menjadi
suatu epidemi global yang tidak membedakan
pria maupun wanita, serta tidak mengenal
batas geografis dan sosio-ekonomis.
• Sindrom Koroner Akut (SKA) adalah salah satu
manifestasi klinis Penyakit Jantung Koroner
(PJK) yang utama dan paling sering
mengakibatkan kematian.

3 4
• Mekanisme terjadinya SKA adalah disebabkan • Manifestasi klinis SKA dapat berupa angina
oleh karena proses pengurangan pasokan pektoris tidak stabil/APTS, Non-ST elevation
oksigen akut atau subakut dari miokard, yang myocardial infarction / NSTEMI, atau ST
dipicu oleh adanya robekan plak aterosklerotik elevation myocardial infarction / STEMI.
dan berkaitan dengan adanya proses
inflamasi, trombosis, vasokonstriksi dan
mikroembolisasi.

5 6
• SKA merupakan suatu keadaan gawat darurat
jantung dengan manifestasi klinis berupa
keluhan perasaan tidak enak atau nyeri di
dada atau gejala-gejala lain sebagai akibat
iskemia miokard.
• Manajemen DRPs adalah suatu proses yang
meliputi semua fungsi yang perlu untuk
menjamin terapi obat kepada pasien yang
aman, efektif dan ekonomis yang dilaksanakan
secara terus menerus.

7 8
• Manajemen DRPs terdiri dari fungsi utamanya
adalah: mengidentifikasi masalah-masalah
yang berkaitan dengan DRPs baik yang
potensial maupun aktual, mengatasi DRPs
yang aktual dan mencegah terjadinya DRPs
yang potensial.
• SKA merupakan salah satu bentuk manifestasi
klinis dari PJK akibat utama dari proses
aterotrombosis.
• Aterotrombosis merupakan suatu penyakit
kronik dengan proses yang sangat komplek
dan multifaktor serta saling terkait.

9 10
• Aterotrombosis terdiri dari aterosklerosis dan
trombosis.
• Aterosklerosis merupakan proses
pembentukan plak (plak aterosklerotik) akibat
akumulasi beberapa bahan seperti lipid-filled
macrophages (foam cells), massive
extracellular lipid dan plak fibrous yang
mengandung sel otot polos dan kolagen.

11 12
• Sedangkan trombosis merupakan proses • SKA disebabkan oleh obstruksi dan oklusi
pembentukan atau adanya darah beku yang trombotik pembuluh darah koroner, yang
terdapat di dalam pembuluh darah atau disebabkan oleh plak aterosklerosis yang
kavitas jantung. vulnerable mengalami erosi, fisur, atau ruptur.

13 14
• Penyebab utama SKA yang dipicu oleh erosi,
fisur, atau rupturnya plak aterosklerotik
adalah karena terdapatnya kondisi plak
aterosklerotik yang tidak stabil (vulnerable
atherosclerotic plaques) dengan karakteristik;
lipid core besar, fibrous cups tipis, dan bahu
plak (shoulder region of the plague) penuh
dengan aktivitas sel-sel inflamasi seperti sel
limfosit T dan lain-lain.
15
• Erosi, fisur, atau ruptur plak aterosklerosis (yang
sudah ada dalam dinding arteri koronaria)
mengeluarkan zat vasoaktif (kolagen, inti lipid,
makrofag dan tissue factor) ke dalam aliran
darah, merangsang agregasi dan adhesi
trombosit serta pembentukan fibrin, membentuk
trombus atau proses trombosis.
• Trombus yang terbentuk dapat menyebabkan
oklusi koroner total atau subtotal.
16
 Penatalaksanaan
• Prinsip penatalaksanaan SKA adalah
mengembalikan aliran darah koroner dengan
trombolitik/ PTCA primer untuk
menyelamatkan jantung dari infark miokard,
membatasi luasnya infark miokard, dan
mempertahankan fungsi jantung.

17 18
 IGD
• Pasien-pasien yang tiba di UGD, harus segera
dievaluasi karena kita berpacu dengan waktu
dan bila makin cepat tindakan reperfusi
dilakukan hasilnya akan lebih baik. Tujuannya
adalah mencegah terjadinya infark miokard
ataupun membatasi luasnya infark dan
mempertahankan fungsi jantung.

19 20
 • Diagnosa Risiko:
Berdasarkan diagnosa dari UA atau NSTEMI,
level risiko akan kematian dan iskemia kardiak
non fatal harus dipertimbangkan / didiagnosa.
• Pengobatan dilakukan berdasarkan level risiko
ini. Diagnosa suatu risiko itu multivariable,
berikut ini adalah prosedur / tahapan garis
besarnya.

21 22
Pasien risiko rendah
• Tidak ada sakit dada berulang saat perioda
observasi, tidak ada tanda angina saat
istirahat, tidak ada peningkatan troponin atau
marker biokimia lain,
• EKG normal atau tidak ada perubahan selama
episode ketidaknyamanan dada.

23 24
25 26
27 28
29 30
31 32
33 34
35 36
37 38
39 40
Ph-Care Plan

41 42
Ph-Care Sebelum Ke RS Di RS
• IGD
Rencana Pharmaceutical Care yang dibuat
harus mencakup dan mempunyai tujuan
dalam hal menjamin dan memastikan
ketersediaan dan distribusi barangbarang
kefarmasian untuk terlaksananya
terapi/penatalaksanaan pasien SKA secara
optimal.

43 44
45 46
47 48
49 50
51 52
 • ACE-I
• Pertama kali obat ini digunakan untuk
mengontrol tekanan darah, atau dikenal juga
dengan kelompok obat antihipertensi. Obat ini
selain dengan baik dapat mengontrol tekanan
darah, juga sangat bermanfaat menjaga dan
melindungi jantung.
• Dengan kata lain, obat ini walau dengan kondisi
tekanan darah penderita normal juga tetap
diberikan, dengan tujuan untuk menjaga dan
memelihara kondisi jantung agar tetap baik.

53 54
55 56
57 58
 FARM NOTES

59 1

Problems
 In this system, problems that have been
identified are addressed systematically in a
pharmacist’s note under the headings Findings,
Assessment, Resolution, and Monitoring.
 The sections of the pharmacist’s note can be
easily recalled with the mnemonic FARM.
Identification of Drug-Related
 The first step in the construction of a FARM note
is to clearly state the nature of the drug-related
problem(s). Each problem in the FARM note
should be addressed separately and assigned
as equential number
 Understanding the types of problems that may
occur facilitates identification of
pharmacotherapy problems. Eight types of
medication-related problems have been
identified.

2 3
 1. Untreated indications
 2. Improper drug selection
 3. Subtherapeutic dosage
 4. Failure to receive drugs
 5. Overdosage
 6. Adverse drug events
 7. Drug interactions
 8. Drug use without indication
4 5
 Use of a classification system such as this for the various
types of medication-related problems offers at least two
advantages.
 First, it presents a framework, applicable in any practice
setting, to assure that the pharmacist has considered
each possible type of problem.
 Second, categorization allows optimal data analysis and
retrieval capabilities.
 Thus, problems as well as the interventions to resolve
them can be stored in a standardized format in a
computer

 When later analysis of this information is needed,
such as determining how much money was
saved through an intervention, how out comes
were improved by thepharmacist, or how many
problems of a certain type have occurred, the
problems and interventions can be reviewed by
groups rather than individually.
6 7
Documentation of Findings
 Each statement of a drug-related problem
should be followed by documentation of the
pertinent findings (F) indicating that the problem
may (potential) or does (actual) exist.
 Information included in this section should
include a summary of the pertinent information
obtained after collection and thorough
assessment of the available patient information.
 Assessment of Problems

 Demographic data that may be reported  The assessment (A) section of the FARM note
include a patient identifier (name, initials, or includes the pharmacist’s evaluation of the
medical record number), age, race (if current situation(i.e., the nature, extent, type,
pertinent), and gender. and clinical significance of the problem).

 As noted earlier under the section on SOAP  This part of the note should delineate the
notes, medical information included in the note thought process that led to the conclusion that
should include both subjective and objective a problem did or did not exist and that an active
findings that indicate a drug-related problem. intervention either was or was not necessary

8 9
 If additional information is required to
satisfactorily assess the problem and make
recommendations, this data should be stated
along with its source (e.g., the patient,
pharmacist, physician).
 The severity or urgency of the problem should be
indicated by stating whether the interventions
that follow should be made immediately or
within one day, one week, one month, or longer.
10
 The desired therapeutic end point or outcome
should be stated. This may include both short-
term goals (e.g., lower blood pressure to
<140/90mmHg in a patient with primary
hypertension [therapeutic end point]) and long-
term goals (e.g., prevent cardiovascular
complications in that patient [therapeutic
outcome].
11
Problem Resolution
 The resolution (R) section should reflect the actions
proposed (or already performed) to resolve the
drug-related problem based upon the preceding
analysis.
 The note should convey that, after consideration of
all appropriate therapeutic options, the option(s)
considered to be the most beneficial was either
carried out or suggested to someone else (e.g., the
physician, patient, or caregiver).
12
 Recommendations may include nonpharmacologic
therapy, such as dietary modification or assisting devices
(e.g., canes, walkers); the rationale for this method of
treatment should be described.
 If pharmacotherapy is recommended, a specific drug,
dose, route, schedule, and duration of therapy should
be specified. It is not sufficient to simply provide a list of
choices for the prescriber
13
 Importantly, the rationale for selecting the particular  Conversely, if certain types of information will be
regimen(s) should be stated. It is reasonable to include withheld from the patient, the reasons for doing
alternative regimens that would be satisfactory if the
so should be stated.
patient is unable to complete treatment with the initial
regimen because of adverse effects, allergy, cost, or
other reasons.
 If no action is recommended or was taken, that
should be documented as well. In this situation,
 If patient counseling is recommended, the information the note serves as a record of the pharmacist’s
that will be included in the counseling session should be involvement in the patient’s care. The
included.
pharmacist then has documentation that
patient care activities were performed

14 15
 Monitoring for End Points and
Outcomes
 It is not enough, however, to only provide a clear,
Ifthere is no concise record of the nature of a problem, the
assessment that led to the conclusion that a problem
documentation, then it exists, and the selection of a plan for resolution of
theproblem.
didn’t happen.
 In the spirit of pharmaceutical care, the patient must not
be abandoned after an intervention has been made. A
plan for follow-up monitoring (M) of the patient must be
documented and adequately implemented

16 17
 This process is likely to include questioning the patient, gathering

laboratory data, and performing the ongoing physical assessments
 Potential adversereactions should be
necessary to determine the effect of the plan that was precisely described along with the
implemented to assure that it results in an optimal outcome for the
patient. method of monitoring. For example, rather
than stating “monitor for GI complaints,”
 Monitoring parameters to assess efficacy generally include the recommendation may be to “question
improvement in or resolution of the signs, symptoms, and laboratory
abnormalities that were initially assessed. The monitoring parameters the patient about the presence of
used to detect or prevent adverse reactions are determined by the dyspepsia, diarrhea, or constipation.”
most common and most serious events known to be associated with
the therapeutic intervention.

18 19

 The frequency, duration, and target endpoint for each
monitoring parameter should be identified. The points at
which changes in the plan may be warranted should be
included.
 For example, in the case of a patient with dyslipidemia, one
may recommend to “obtain fasting HDL, LDL, total
cholesterol, and triglycerides after 3 months of treatment. If
the goal LDL of <100 mg/dL is not achieved with good
compliance at 3 months, increase simvastatin to 40 mg po
QD. If goal LDL is achieved, maintain simvastatin 20mg po QD
and repeat fasting lipoprotein profile annually.”
20
SUMMARY
 A SOAP or FARM progress note constructed in the manner
described identifies each drug-related problem and states the
pharmacist’s Findings observed, an Assessment of the findings, the
actual or proposed Resolution of the problem based upon the
analysis, and the parameters and timing of follow-up Monitoring.
Either form of note should provide a clear, concise record of
process, activity, and projected follow-up.
 When written for each medication-related problem, these notes
should provide data in a standardized, logical system. In particular,
FARM notes provide a convenient format for progress notes for all
pharmacists, applicable to any practice setting.
21
 TUGAS ASUHAN KEFARMASIAN

HORMON

DISUSUN

OLEH:

KELOMPOK III

ANGGOTA KELOMPOK:

ERNI LISTIANI SIHOMBING 163202182

ASTUTI REMALYA 163202183

Reference RIZKI SULIYAN 163202184

REZKI SURYA NINGSIH 163202185
YOHANA PERANGIN-ANGIN 163202186
 Timothy J. Ives, Bruce R. Canaday, Peggy C. Yarborough, SAFRITA MAWADDAH 163202187
“Documentation of Pharmacist Interventions” in Instructor’s Guide to
HENDRA SAPUTRA 163202188
accompany Pharmacotherapy Casebook, 5e
IMELDA ROSULINA SITORUS 163202189
MAYA AYU PUSPITA 163202190
MILVA MAHRINA TANJUNG 163202191
LIAN PEBRIANA SITUMORANG 163202192

PROGRAM STUDI PROFESI APOTEKER

FAKULTAS FARMASI

UNIVERSITAS SUMATERA

2017

22
PENYAKIT ALZHEIMER
1. DEFINISI
Penyakit Alzheimer adalah proses degenerative yang terjadi pertama-tama pada
sel yang terletak pada dasar dari lobus frontalis,temporal dan oksipitalis,yang
mengirim informasi ke korteks serebral dan hipokampus. Sel yang terpengaruh
pertama kali kehilangan kemampuannya untuk mengeluarkan asetilkolin, lalu terjadi
degenerasi. Jika degenerasi ini mulai berlangsung, tidak ada tindakan yang dapat
dilakukan untuk menghidupkan kembali sel-sel itu atau menggantikannya.
Penyebabnya sering kali tidak diketahui meskipun beberapa riset sedang dan telah
dilakukan dalam beberapa area seperti genetic, virus-virus lambat dan factor
lingkungan.
2. EPIDEMIOLOGI
Penyakit Alzheimer mengenai sekitar 5 juta orang amerika serikat dan lebih dari
30 juta orang di seluruh dunia. Peningkatan jumlah penderita penyait Alzheimer di
Negara-negara industry adalah seiring dengan peningkatan angka harapan hidup usia
tua yang kian pesat di Negara-negara tersebut. Beberapa hal yang berkaitan dengan
epidemiologi yaitu :
 Faktor demografi
Insiden demensi meningkat sesuai umur, dimana mengenai 15-20 % individu
diatas usia 60 tahun dan 45% diatas usia 80 tahun. Berdasarkan gender terdapat
perbedaan frekuensi etiologi dimana untuk pria terdapat angka yang tinggi untuk
demensia yang disebabkan oleh kelainan vascular dibanding yang disebabkan oleh
penyakit Alzheimer. Secara keseluruhan frekuensi demensia adalah sama pada
wanita dan pria meski beberapa studi menunjukkan bahwa resiko untuk terkena
Alzheimer adalah lebih tinggi wanita dibanding pria oleh karena hilangnya efek
neurotropik dari estrogen pada wanita di usia menopause.
 Tren
Secara dramatis, peningkatan angka harapan hidup juga meningkatkan angka
penyakit demensia. Mereka yang memiliki keluarga dekat yang menderita demensia
memiliki kecenderungan lebih tinggi untuk terkena demensia dibandingkan populasi
lain. Dan mereka yang menderita down syndrome cenderung untuk terkena demensia
Alzheimer.
Tingkat pendidikan yang rendah juga disebutkan berhubungan dengan risiko
terjadinya penyakit Alzheimer. Faktor-faktor risiko lain yang dari berbagai
penelitian diketahui berhubungan dengan penyakit Alzheimer adalah
hiperetensi, diabetesmelitus,dislipidemia, serta berbagai faktor risiko timbulnya
aterosklerosis dan gangguan sirkulasi pembuluh darah otak.Mutasi beberapa
gen familial penyakit Alzheimer pada kromosom21,koromosim 14,dan
kromosom 1 ditemukan pada kurang dari 5% pasien denganpenyakit
Alzheimer. Sementara riwayat keluarga dan munculnya alel e4 dari
4Apolipoprotein E pada lebih dari 30% pasien dengan penyakit ini
mengindikasikanadanya faktor genetik yang berperan pada munculnya penyakit
ini. Seseorang dengan riwayat keluarga pada anggota keluarga tingkat pertama
mempunyai risiko dua sampai tiga kali menderita penyakit Alzheimer,
walaupun sebagaian besar pasien tidak mempunyai riwayat keluarga yang
positif. Walaupun alel e4 Apo E bukan penyebab timbulnya demensianamun
munculnya alel ini merupakan faktor utama yang mempermudah seseorang
menderita penyakit Alzheimer
3. HORMON ESTROGEN
Estrogen adalah sebutan untuk sekelompok hormon yang berperan penting
dalam perkembangan dan pertumbuhan karakteristik seksual wanita serta proses
reproduksi. Hormon ini sebenarnya tidak hanya diproduksi dalam tubuh perempuan,
tapi juga terdapat dalam tubuh pria dalam kadar yang jauh lebih rendah. Hanya saja
peran hormon estrogen dalam tubuh pria belum diketahui secara pasti.
Hormon sendiri adalah substansi kimia yang berperan penting dalam tubuh
manusia dan mengalir ke seluruh tubuh, umumnya melalui pembuluh darah. Secara
umum, hormon berperan dalam:
 Membawa pesan atau instruksi dari satu kelompok sel ke kelompok sel lain.
 Memengaruhi fungsi organ dan sel.
 Mengatur perkembangan dan metabolisme tubuh.
 Menentukan fungsi seksual dan jaringan reproduksi.
 Berdampak kepada mood.
 Mengatur bagaimana tubuh memanfaatkan asupan makanan yang masuk.
 Mengelola reaksi tubuh terhadap bahaya.
Hormon estrogen ini diproduksi oleh indung telur, jaringan lemak, dan kelenjar
adrenal. Kelompok hormon ini terdiri dari estriol, estron, serta estradiol. Hormon
estradiol memiliki kadar paling tinggi pada masa reproduksi wanita. Estriol
diproduksi oleh plasenta selama masa kehamilan, sementara estradiol dan estron
diproduksi terutama oleh indung telur pada masa pramenopause. ketiga jenis
estrogen tersebut dibuat dari androgen dengan bantuan enzim. Estradiol dibuat dari
testosteron, sedangkan estron dibuat dari androstenadion. Estron bersifat lebih lemah
daripada estradiol, dan pada wanita pascamenopause estron ditemukan lebih banyak
daripada estradiol. Berbagai zat alami maupun buatan telah ditemukan memiliki
]
aktivitas bersifat mirip estrogen . Zat buatan yang bersifat seperti estrogen disebut
xenoestrogen, sedangkan bahan alami dari tumbuhan yang memiliki aktivitas seperti
estrogen disebut fitoestrogen.
Estriol
Estradiol
Estron
Kadar normal
Kisaran normal estrogen bergantung pada usia. Wanita berusia antara 20 sampai
29 tahun memiliki tingkat estrogen rata-rata 149 pg/ml (piktogram per mililiter).
Seorang wanita berusia 30 hingga 39 tahun rata-rata memiliki kadar 210 pg/ml.
Sedang perempuan berusia lebih dari 40 tahun dan belum mengalami menopause
akan memiliki tingkat estrogen rata-rata 152 pg/ml. Tingkat rata-rata dapat bervariasi
dari hari ke hari tergantung pada siklus haid tiap wanita.
4. MEKANISME KERJA HORMON ESTROGEN PADA PENGOBATAN
ALZEIMER
Estrogen diduga terlibat dalam menstimulasi pertumbuhan neuronal dan
mencegah kerusakan oksidatif yang akan menguntungkan sel yang terekpos βAP.
Dalam hippocampus, korteks serebral, dan basal otak depan, reseptor estrogen
terlokalisasi bersama dengan reseptor faktor pertumbuhan saraf pada ujung saraf
kolinergik. Kehadiran reseptor estrogen meningkatkan jumlah reseptor faktor
pertumbuhan saraf. Kemampuan estrogen berinteraksi dengan faktor pertumbuhan
saraf dapat menjelaskan kemampuan estrogen dalam menstimulasi pertumbuhan
sinaptik stimulasi akson dan dendrite untuk membentuk cabang baru.
Suplemen estrogen dapat mencegah penurunan up take kolin dan konsentrasi
asetilkolin transferase. Estrogen penting memelihara neurotransmitter kolinergik
normal. Estrogen meningkatkan jumlah reseptor N-metil-D-Aspartat (NMDA) dalam
daerah otak yang terlibat dalam proses perekaman memori baru, dan mencegah
kerusakan sel, karena bertindak sebagai antioksidan. Estrogen mencegeh
pembentukan plak neuritis dengna memfasilitasi degradasi APP lebih cenderung oleh
α sekretase daripada β sekretase, sehingga menghasilkan produk terlarut yang tidak
merugikan. Meskipun demikian, ada data yang justru sangat berlawanan dengan hal
diatas, dimana risiko Alzheimer pada wanita yang sedang mendapat terapi estrogen
(ERT) justru meningkat. Namun beberapa studi epidemiologic juga menunjukkan
penurunan risiko alzeimer pada wanita yang mengkonsumsi estrogen, meski studi
yang lebih terkontrol belum ada, oleh karena itu peranan estrogen dalam etiologi dan
pencegahan Alzheimer masih dielusidasi.
Mekanisme kerja golongan obat inhibitor kolinesterase
 Donepezil
Merupakan pipiridine cholinesterase inhibitor. Cara kerjanya dengan
menghambat enzim acetylcholinesterase secara reversible dan kompetitif.
Digunakan untuk pengobatan ringan hingga sedang, adverse reaction yng biasa
muncul antara lain mual, muntah, dan diare.
  Galantamine 7. INTERAKSI OBAT ESTROGEN DENGAN OBATALZHEIMER
Mekanisme kerjanya dengan memperlambat degradasi asetilkolin dikorteks
serebral dan juga mengatur reseptor nikotinik asetilkolin untuk meningkatkan
aetilkolin di presinapsis saraf. Selain itu dapat meningkatkan level serotonin dan
glutamate. Biasanya digunakan untuk alzeimer ringan hingga sedaang. Efek
samping yang mungkin muncul antara lain mual, muntah, diare yang mana ketiga
hal ini berkaitan dengan efek kolinergiknya
 Rivastigmine
Selain memiliki aktivitas pada asetilkolinesterse juga memiliki aktivtas
butirikolinesterase. Asetilkolinisterse memiliki 2 bentuk, yaitu globural 1 dan
globural 4 yang mana globural 1 lebih banyak daripada globural 4. Dalam hal ini,
rivastigmine dapat mencegah degradasi asetilkolin pada again globural 1
sehingga menyebabkan obat ini menjadi lebih poten. Rivastigmine biasa
digunakan untk mengobati alzeimer ringan hingga sedang.

5. DOSIS PEMBERIAN HORMON ESTROGEN PADA PENGOBATAN

ALZEIMER
 Donepezil
Dosis : 5 mg pada malam hari Interaksi estrogen dengan obat2 yang
 Rivastigmin direkomendasikanuntukmemperlambatkondisi Alzheimer. Dari

Dosis : 1.5 mg dua kali sehari gambardiatasterlihattidakadanyainteraksiantara estradiol denganobat – obat

 Galantamine Alzheimer.

Dosis : 4 mg dua kali sehari

6. EFEK SAMPING  Interaksiobat estrogen denganobat-obatterapi untuk behavioural and

 kesehatan jaringan otak mengalami penurunan, menyebabkan menurunnya psychological symptoms of dementia (bpsd)

daya ingat dan kemampuan mental.

 Menimbulkan pendarahan mirip menstruasi (menstruation-like bleeding) dan
dapat menimbulkan hiperplasia endometrium kecuali bila diberikan
progesteron secara siklik
 Bila diberikan pada laki-laki,dapat menimbulkan feminisasi.
 Pemberian estrogen pada wanita hamil dapat menimbulkan kelainan genetik
pada keturunannya. Padapenggunaanobat-obatperedagejalakebiasaandanpsikoligis,
misalnyapadakondisiagitasi yang di deritapasien Alzheimer, carbamazepine
dilaporkanmenurunkanagitasi yang
 berhubungandengangangguanpsikisdanmengurangiefeksampingneuroleptis. h) Penilaian kebiasaan dengan cermat dan perencanaan dengan hati-hati dari
Namunpadapemberiankombinasi, carbamazepine dan hormone estrogen faktor lingkungan harus dilakukan sebelum inisiasi terapi obat untuk gejala
mengalamiinteraksi. Mekanismeinteraksiinidisebabkan carbamazepine kebiasaan sehari-hari.
menginduksienzim CYP3A4 yang berperanmemetabolisme estrogen, Farmakoterapi untuk gejala sehari-hari harus dibatasi pada masing-masing
sehinggakadar plasma estrogen pasien, dan dosis pengobatan menurun dan berhenti pada pasien dengan gejala
menurundengancepatakibattingginyakecepatanmetabolism yang stabil.
II. Terapi Non Farmakologi
Terapi nonfarmakologi merupakan kunci utama dalam menangani Alzheimer,
diantaranya:
a) Buatlah permintaan dan perintah pada pasien Alzheimer sesederhana mungkin,
dan hindari tugas yang rumit yang dapat menyebabkan frustasi
begitujugadenganpemberianobat “off label” untukmeningkatkan mood
b) Hindari konfrontasi dan penolakan yang bias menyebabkan frustasi
pasien, ternyatakombinasidengan estrogen meningkatkankadar estradiol
c) Tetap tenang, dan selalu mendukung jika pasien menjadi sangat
didalamseldengancaramempengaruhi transporter P-glikoprotein.
membingungkan
d) Jagalah kondisi lingkungan tempat tinggal tetap konsisten dan hindari
8. KIEPASIEN PENGOBATAN ALZHEIMER
perubahan yang tidak perlu
I. Prinsip Farmakoterapi
e) Sediakan alat bantu untuk mengingatkan, menjeklaskan, dan menunjuk arah
a) Evaluasi pasien harus cermat untuk menguji penyebab demensia dan
pada pasien Alzheimer
memperhatikan kelainan lain yang terjadi sebelum mempertimbangkan terapi
f) Sadarilah penurunan kapasitas dan tingkatkan harapan untuk performans pasien
obat
yang lebih baik
b) Etiologi Alzheimer, farmakoterapi baik obat maupun permasalahan
g) Jika terjadi penurunan fungsi yang tiba-tiba dan gejala yang darurat, segera
patofisiologi, belum begitu jelas diketahui
bawa ke tenaga profesional
c) Terapi nonobat dan dukungan sosial untuk pasien dan keluarga adalah
pengobatan primer untuk Alzheimer. Untuk pasien:
d) Edukasi pengurus dan keluarga mengenai penyakit dan keterbatasan
 Ciptakan rasa tenang dan stabil dilingkungan rumah
pengobatan perlu dilakukan. Penyerahan yang tepat kepada keluarga dan
 Minimalkan situasi yang dapat memicu agitasi dan kegelisahan
dukungan legal harus diciptakan.
 Sebisa mungkin, lakukan aktivitas terstruktur sepanjang hari coba terus
e) Farmakoterapi berorientasi terhadap mengatasi gejala dan mencegah
memngingat apa yang diminati
penurunan keburukan fungsi kognisi.
 Obat-obatan mungkin akan diresepkan dokter untuk mengontrol emosi dan
f) Penilaian awal yang cermat, menggunakan skala rating, harus dilakukan
gejala kognitif penyakit Alzheimer
sebelum inisiasi terapi obat untuk gejala sehari-hari dan kognisi.
 Kerjakan apapun yang disarankan untuk menghindari komplikasi berbahaya
g) Titrasi dosis perlahan dengan monitoring dengan hati-hati dapat
dari penyakit ini, seperti pneumonia dan infeksi lainnya, jatuh dan fraktur
meminimalisasi efek samping obat.
tulang
 Untuk keluarga dan perawat:

 Minta bantuan orang lain saat dirasa butuh

 Kelola kesehatan anda
 Tanyakan apa yang dibutuhkan pasien, terutama kebutuhan medisnya
 Bersiaplah, mungkin akan dating hari dimana pasien membutuhkan
fasilitas perawatan , seperti panti, saat mereka menjadi luar biasa dan
tidak bias dirawat di rumah
 Bergabunglah dengan kelompok dukungan sesame pasien atau hadiri
program edukasi tentang penyakit Alzheimer

9. CONTOH SEDIAAN HORMON ESTROGEN PADA PENGOBATAN

ALZEIMER

Pharmacoterapy Work-Up
Notes

1
2 3
4 5
6 7
8 1
 PHARMACEUTICAL CARE
PRACTICE
Think like a practitioner - Pharmacotherapy
Workup
Act like a practitioner - Standards of Practice
Speak like a practitioner - Practice Vocabulary
2 3
Pharmacotherapy Workup
 Sistematis, terstruktur, proses rasional (logis)
 Mirip dengan HCP lain namun fokus pada
pharmacotherapy
 Identifikasi, pemecahan & pencegahan masalah
berkaitan dengan indikasi, efikasi, Keamanan or
kepatuhan.
• Penerapan pengetahuan ilmiah kepada perawatan
pasien.
 Ada Dua pertanyaan Dasar: PHARMACEUTICAL CARE
PRACTICE
Apakah masalah pasien disebabkan oleh terapi “We work directly with patients to get
obat? the results they want from their
medications.”
R.J. Cipolle
Dapatkah masalah pasien ditangani oleh terapi
obat?

4 5
 Drug therapy problems bisa terjadi dimana saja dalam
Struktur Dasar Pharmacotherapy Workup Proses penggunaan obat pasien
Untuk mengevaluasi keefektifan dan keamanan dari
Terapi obat seorang pasien
Drug Therapy Problem Drug Therapy Problem
Terapi obat tidak perlu
Effectiveness Perlu tambahan terapi obat
Dosis terlalu rendah Effectiveness
Dosis terlalu tinggi

Indication Drug product Dosage regimen Outcomes Indication Drug product Dosage regimen Outcomes

Safety Safety
Drug Therapy Problem Drug Therapy Problem
understand and assess Determine the Evaluate the DOSAGE Obat tidak efektif ketidakpatuhan
what are the OUTCOME(S)
the INDICATION for the PRODUCT Regimen actually being (positives/negatives) Adverse drug reaction
drug therapy being used taken

Drug therapy problems mencegah tercapainya hasil terapi yang positif.

6 7
 Causes of Drug Therapy Problems
 Unnecessary drug:
 No indication
 Addictive drug use
 Non drug therapy more
appropriate
 Duplicate therapy
 Treating avoidable adverse
effects
 Wrong Drug
 Dosage form inappropriate
 Contraindication present
 Condition refractory to drug
 More effective drug available
 Dosage too low
 Wrong dose
 Frequency inappropriate
 Duration inappropriate
 Incorrect storage
 Incorrect administration
 Drug interaction
 Adverse drug reactions
 Unsafe drug for patient
 Incorrect administration
 Drug interaction
 Dosage increase or decrease
too quickly
 Undesirable effects
8 9
Causes of Drug Therapy Problems; contd
 Dosage too high  Needs additional drug
 Wrong dose therapy
 Frequency inappropriate  Untreated condition
 Duration inappropriate
 Synergistic therapy
 Drug interaction
 Prophylactic therapy
 Inappropriate
compliance
 Drug product not available
 Cannot affoard drug product
 Cannot swallow/adminster
drug
 Does not undersatnd
instructions
 Patient prefers not to take
drugs
Requirements for the Pharmaceutical Pharmacotherapy Workup Medication Experience

Care Practitioner
 Understand your responsibilities Pharmacotherapy Workup

 Develop a therapeutic relationship with each

patient Medication Experience

 Apply the Pharmacotherapy Workup to make

rational drug therapy decisions
 Learn the patient care process
 Document all care provided
 Acquire an appropriate pharmacotherapeutic
knowledge base
 Develop clinical skills
 Understand practice standards and ethical
considerations

10 11
12 13
 What is the Mission of our profession?

To Serve Society

14 15
Operational definition of pharmaceutical
care COSTS OF DRUG THERAPY
PROBLEMS
Total U.S. Costs = $177 billion / year
 A pharmacist practices pharmaceutical care when  Physician/Urgent Care Visits $ 14 billion
he/she finds and fixes or prevents drug therapy  +Added Medications $ 3 billion
problems (DTPs)  +Emergency Room Visits $ 6 billion
in patients.  +Hospital Visits $ 121 billion
 +Long-term Care Stays $ 33 billion

Ernest FR and Grizzle AJ. Drug-Related Morbidity and Mortality:

Updating the Cost-of-Illness Model J. APhA 41: March 2001

16 17
Effect of a training program on community pharmacists'
detection of and intervention in drug-related problems.
OBJECTIVE: To develop and present a pharmaceutical care training program
for pharmacists, and to examine the ability of these pharmacists
to provide pharmaceutical care in a community pharmacy setting.
DESIGN: Prospective, randomized study.
INTERVENTION: A 40-hour pharmaceutical care training program was developed
and presented to pharmacists, and 1,078 patients were randomly assigned to
receive either (1) traditional pharmacy services or (2) pharmaceutical care,
consisting of initial patient work-up and follow-up with documentation in a
patient record.
MEASUREMENTS: The study period was six months. Pharmacists documented
problems identified, actions taken, and time required for all patients.
Currie JD, Chrischilles EA, Kuehl AK, Buser RA. J Am Pharm Assoc (Wash).
1997 Mar-Apr;NS37(2):181.
18
Effect of a training program on community pharmacists'
detection of and intervention in drug-related problems.
RESULTS: Pharmacists consistently identified and intervened to address problems
in both study groups. Patients receiving pharmaceutical care were more than seven
times as likely to have any problems identified (odds ratio [OR] 7.5; confidence
Interval [CI] 4.2-13.1), more than eight times as likely to have an intervention
performed (OR, 8.1; CI 4.7-14.2), and more than eight times as likely to have a
drug-related problem identified (OR 8.6; CI 4.8-15.5) than were patients receiving
traditional pharmacy services only. Time spent counseling patients was similar for
the two groups.
CONCLUSIONS: The training program proved to be an effective way to increase
the number of problems identified and addressed by pharmacists.
Currie JD, Chrischilles EA, Kuehl AK, Buser RA. J Am Pharm Assoc (Wash).
1997 Mar-Apr;NS37(2):181.
19
Medical problems
Patient needs of drug therapy
 A disease state
 A change in physiology that (potentially) results in
clinical evidence of damage to an organ system
 Drug therapy problems occur when one or more of a
patient’s needs for drug therapy are not met

Drug Therapy Problems

A patient problem that is either caused by a drug

or may be treated/prevented by a drug

20 21
5 patient needs for drug therapy
 (1) every drug has an appropriate indication
 (2) drug therapy is effective
 (3) drug therapy is safe
 (4) patients can comply with drug therapy
 (5) no untreated indications are present
22
Who is at risk?
 Prescribed multiple chronic meds & are diagnosed
with a chronic disease.
 Take many doses of meds daily
 Inadequate response to medication treatments
 Take drugs with narrow therapeutic indexes
 Suspected to be non-adherent to drug therapy
23
 Concisely Stating DTPs
Who is at risk?
• What is the patient name?
 Identified as having difficulty managing
medication because of physical (visual) or • Is the problem is actual or potential?
cognitive limitations (literacy, language, • What is the symptom or problem?
knowledge) • What is the type of DTP?
 Symptoms suggesting ADRs • What is the relationship or potential
 Risk of drug toxicities or have experienced drug
relationship to drug therapy?
toxicities.
 Major changes in the medication regimen after a
hospital discharge or have had a history of
frequent admissions

24 25
 State the patient name
Example # 1
Anne is a 30 year old mother with a child two years of age. She comes to
your pharmacy today to ask your opinion on products used to treat vaginal
either he/she infections. In response to your questions, she reveals that she has had
is experiencing vaginal discharge with no odor and vaginal itching for two days. She had
or problems like this a year ago and her doctor gave her a Monistat preparation.
is at risk for She has just finished a course of Keflex for a urinary tract infection. She says
that there is no way she can be pregnant.
State Anne’s DTP
State the problem (symptom)
Anne ( patient name) is experiencing (actual problem)
vaginal itching and discharge ( symptoms) as a result
as a result of
or
of an ADR ( a DTP) from recent Keflex therapy
possibly due to ( relationship to drug therapy)

Type of DTP &

Relationship to drug therapy

26 27
 Example # 2
Sam is a 7 year old boy(25 kg. having a prescription filled for Augmentin 5 ml. TDS Pharmaceutical care practitioners
for 10 days. His mother explains that he has been diagnosed with otitis media and
That the physician also suggested paracetamol for the earache. use an organized approach to
determine if all the patients drug
State Sam’s DTP
therapy needs are met &
Sam ( patient name) is at risk (potential problem) of finds and fixes or prevents drug
suffering from prolonged otitis media ( symptoms) therapy problems (DTPs) in patients.
possibly due to receiving too low a dose ( a DTP) of
syrup Augmentin ( relationship to drug therapy)

28 29
 The Pharmacy Care Process
ASSESSMENT ASSESSMENT
 Evaluate appropriateness, effectiveness,

Experienced Decision Making

safety, and compliance with medications
Patient Practitioner
 Identify drug therapy problems
Begin Here
Medication Experience

CARE PLAN
 Resolve drug therapy problems
 Establish goals of therapy
 Today’s wants  Interventions  Philosophy of Practice

Determine what your patient Wants

and needs
 Social Obligation
 Responsibility  Responsibility to
to participate
in information
FOLLOW-UP identify, resolve,
and prevent (Expectations and Goals)
sharing and drug therapy
decision making  Evaluate progress in meeting goals of problems
therapy  Patient-centered
 Record actual patient outcomes
 Reassess new problems
approach Determine what your patient does Not Want
 Caring
(Concerns)
Therapeutic Relationship

30 31
 ASSESSMENT ASSESSMENT
Primary sources of information:
Patient Other sources of information:
Family
Caregivers Prescribers
Texts Medication profiles
Literature Medical chart
Laboratory test results

32 33
 Assessment: How
 Meet the patient DRUG THERAPY PROBLEM
 Establish the therapeutic relationship
 Elicit / Retrieve relevant information from the The Identification, resolution and prevention of drug
patient therapy problems are The Heart and The Soul of
 Determine who your patient is as an individual Pharmaceutical Care Practice
 The patient's demographics, medication experience, and other
clinical information
 Make rational drug therapy decisions using the
Pharmacotherapy Workup
 Determine whether the patient's drug-
drug-related needs are
being met (indication, effectiveness, safety, compliance),
identify drug therapy problems

34 35
The purpose of the care plan is to organize all
of the work agreed upon by the practitioner Goals of Therapy
and the patient to achieve the goals of
therapy.
This requires interventions to resolve drug
therapy problems, to optimize the patient’s
medication experience and prevent new drug
therapy problems from developing.
36
 Curing a disease
 Address signs and/or symptoms
 Slow progression of a disease
 Prevent a disease
 Normalize laboratory values
 Assist in the diagnostic process
37
 CARE PLAN
Goals of Therapy
Goals of therapy have a specific structure: GOALS OF THERAPY
...involves the patient
1. clinical parameter signs, symptoms and/or What are your patient’s goals?
laboratory values which are observable,
measurable, and realistic. Discuss with your patient how certain you are that
2. A desired value or observable change in the the drug therapy will be effective at achieving the
parameter goals of therapy.
3. A specific timeframe in which the goal is to
be met Tell your patient when to expect to see the benefit
from drug therapy.

38 39
 CARE PLAN
INTERVENTIONS
The purpose of the follow-up evaluation is to
Initiate new drug therapy determine the actual outcomes of drug
Increase dosages therapy for the patient, compare these
results with the intended goals of therapy,
Decrease dosage and determine the effectiveness and safety of
Discontinue drug therapy pharmacotherapy and the current status of
Referrals the patient.
Provide instructions for optimal use of
medications

40 41
 EVALUATION
FOLLOW-UP
Review EVALUATION ahead of time
your documentation Look for and document:

Make a personal connection GOOD (achieving goals of therapy most

often improvement in the medical condition)
Let your patient tell the story
BAD (side effects, adverse drug reaction,
or toxicity resulting from drug therapies)

“How have you been?” NEW (new problems, noncompliance, new

medical conditions requiring drug therapy)
“What’s happened since our last visit?”
“Let’s go over how well your new
medications are working for you.”

42 43
EVALUATION— EFFECTIVENESS EVALUATION—SAFETY
Evidence: Evidence:
Clinical signs and/or symptoms
(improvements in the presentation of the disease or Clinical signs and/or symptoms
illness) (Undesirable effects of drug therapy)

Laboratory test results

(improvements in the indicators of the disease or Laboratory test results
illness)
(Indicators of harmful effects of drug therapy)

44 45
 Signs & Symptoms

Abnormal Laboratory Values

Documentation
Labs Clinical
 Maintain effective record of
Goals of Therapy Effectiveness  all decisions made concerning the patient's drug therapies
 the outcomes of those decisions
Indication Drug product Dosage regimen Outcomes  it includes
 patient's clinical information,
Toxicity  drug therapy problems,
Adverse Drug Reaction Safety
 medication record,
Labs Clinical  goals of therapy,
 evidence of effectiveness and safety of pharmacotherapies at every
follow--up visit.
follow
 Documentation required to facilitate collaboration
between members of the health care team.

46 47
 Key skills
TEAM WORK
 Patient
Patient--Centered Focus  Mechanism for Conflict
 Establishment of a Resolution
Common Goal  Development of Effective Organisational Clinical
 Understanding of the Communications skills skills
Other Members' Roles  Shared Responsibility for
 Confidence in Other Team Team Actions
Health COMPETENT
Members  Evaluation and Feedback and
Practitioner Ethics &
 Flexibility in Roles fitness
Cultural
 Joint Understanding of awareness
Group Norms Communication
 punctuality or willingness to skills
stay current in one's field

48 49
 BUILDING A PRACTICE Summary
Established Practice Phase
N=1000-2500 Clarifying Pharmaceutical Care
 Pharmacists have 3 questions about PC :

Number  How to provide it

Of  How to overcome obstacles, and
Growth Phase
Patients Learning Phase  How to receive reimbursement for the service
N=250-500
N=50

1-2 months 6-12 months 18-36 months

Time

50 51
 Summar
y
MOST FREQUENT INDICATIONS FOR DRUG THERAPY
Clarifying Pharmaceutical Care (N = 26,238 Patient Encounters)
 PC can be view as “ finding and responding of the 1. HYPERTENSION
drug therapy problems of patients” 2. HYPERLIPIDEMIA
3. DIABETES
 Patient counseling is only one component of
4. OSTEOPORSIS
PC 5. VITAMIN/DIETARY SUPPLEMENT
 The pharmacist’s focus moves from dispensing 6. ALLERGIC RHINITIS
process to patient care 7. ESOPHAGITIS
 The therapeutic relationship- a key feature of 8. DEPRESSION
PC- is a partnership between the pharmacist and 9. MENOPAUSAL SYMPTOMS
patient to work together to prevent, identify, and 10. ARTHRITIS PAIN
solve drug therapy problems. These 10 conditions represent 50% of all indications for drug
therapy

52 53
Confidence & Competence in Pharmaceutical Care Practice

The End

54 55
  In this system, problems that have been
identified are addressed systematically in a
pharmacist’s note under the headings Findings,
Assessment, Resolution, and Monitoring.

FARM NOTES  The sections of the pharmacist’s note can be

easily recalled with the mnemonic FARM.

1 2
Identification of Drug-Related
Problems
 The first step in the construction of a FARM note  1. Untreated indications
is to clearly state the nature of the drug-related  2. Improper drug selection
problem(s). Each problem in the FARM note  3. Subtherapeutic dosage
should be addressed separately and assigned
 4. Failure to receive drugs
as equential number
 5. Overdosage
 Understanding the types of problems that may
 6. Adverse drug events
occur facilitates identification of
pharmacotherapy problems. Eight types of  7. Drug interactions
medication-related problems have been  8. Drug use without indication
identified.

3 4
 Use of a classification system such as this for the various  When later analysis of this information is needed,
types of medication-related problems offers at least two such as determining how much money was
advantages.
saved through an intervention, how out comes
 First, it presents a framework, applicable in any practice were improved by thepharmacist, or how many
setting, to assure that the pharmacist has considered
problems of a certain type have occurred, the
each possible type of problem.
problems and interventions can be reviewed by
 Second, categorization allows optimal data analysis and
groups rather than individually.
retrieval capabilities.
 Thus, problems as well as the interventions to resolve
them can be stored in a standardized format in a
computer

5 6
Documentation of Findings

 Each statement of a drug-related problem  Demographic data that may be reported

should be followed by documentation of the include a patient identifier (name, initials, or
pertinent findings (F) indicating that the problem medical record number), age, race (if
may (potential) or does (actual) exist. pertinent), and gender.

 Information included in this section should  As noted earlier under the section on SOAP
include a summary of the pertinent information notes, medical information included in the note
obtained after collection and thorough should include both subjective and objective
assessment of the available patient information. findings that indicate a drug-related problem.

7 8
Assessment of Problems
 The assessment (A) section of the FARM note
includes the pharmacist’s evaluation of the
current situation(i.e., the nature, extent, type,
and clinical significance of the problem).
 This part of the note should delineate the
thought process that led to the conclusion that
a problem did or did not exist and that an active
intervention either was or was not necessary
9 10
 If additional information is required to
satisfactorily assess the problem and make
recommendations, this data should be stated
along with its source (e.g., the patient,
pharmacist, physician).
 The severity or urgency of the problem should be
indicated by stating whether the interventions
that follow should be made immediately or
within one day, one week, one month, or longer.

 The desired therapeutic end point or outcome
should be stated. This may include both short-
term goals (e.g., lower blood pressure to
<140/90mmHg in a patient with primary
hypertension [therapeutic end point]) and long-
term goals (e.g., prevent cardiovascular
complications in that patient [therapeutic
outcome].
11
Problem Resolution
 The resolution (R) section should reflect the actions
proposed (or already performed) to resolve the
drug-related problem based upon the preceding
analysis.
 The note should convey that, after consideration of
all appropriate therapeutic options, the option(s)
considered to be the most beneficial was either
carried out or suggested to someone else (e.g., the
physician, patient, or caregiver).
12
 Recommendations may include nonpharmacologic
therapy, such as dietary modification or assisting devices
(e.g., canes, walkers); the rationale for this method of
treatment should be described.
 If pharmacotherapy is recommended, a specific drug,
dose, route, schedule, and duration of therapy should
be specified. It is not sufficient to simply provide a list of
choices for the prescriber
13
 Importantly, the rationale for selecting the particular
regimen(s) should be stated. It is reasonable to include
alternative regimens that would be satisfactory if the
patient is unable to complete treatment with the initial
regimen because of adverse effects, allergy, cost, or
other reasons.
 If patient counseling is recommended, the information
that will be included in the counseling session should be
included.
14
 Conversely, if certain types of information will be
withheld from the patient, the reasons for doing
Ifthere is no
so should be stated. documentation, then it
 If no action is recommended or was taken, that
didn’t happen.
should be documented as well. In this situation,
the note serves as a record of the pharmacist’s
involvement in the patient’s care. The
pharmacist then has documentation that
patient care activities were performed

15 16
Monitoring for End Points and
Outcomes
 It is not enough, however, to only provide a clear,
concise record of the nature of a problem, the
assessment that led to the conclusion that a problem
exists, and the selection of a plan for resolution of
theproblem.
 In the spirit of pharmaceutical care, the patient must not
be abandoned after an intervention has been made. A
plan for follow-up monitoring (M) of the patient must be
documented and adequately implemented
17
 This process is likely to include questioning the patient, gathering
laboratory data, and performing the ongoing physical assessments
necessary to determine the effect of the plan that was
implemented to assure that it results in an optimal outcome for the
patient.
 Monitoring parameters to assess efficacy generally include
improvement in or resolution of the signs, symptoms, and laboratory
abnormalities that were initially assessed. The monitoring parameters
used to detect or prevent adverse reactions are determined by the
most common and most serious events known to be associated with
the therapeutic intervention.
18

 Potential adversereactions should be
precisely described along with the
method of monitoring. For example, rather
than stating “monitor for GI complaints,”
the recommendation may be to “question
the patient about the presence of
dyspepsia, diarrhea, or constipation.”
19
 The frequency, duration, and target endpoint for each
monitoring parameter should be identified. The points at
which changes in the plan may be warranted should be
included.
 For example, in the case of a patient with dyslipidemia, one
may recommend to “obtain fasting HDL, LDL, total
cholesterol, and triglycerides after 3 months of treatment. If
the goal LDL of <100 mg/dL is not achieved with good
compliance at 3 months, increase simvastatin to 40 mg po
QD. If goal LDL is achieved, maintain simvastatin 20mg po QD
and repeat fasting lipoprotein profile annually.”
20
SUMMARY Reference

 A SOAP or FARM progress note constructed in the manner  Timothy J. Ives, Bruce R. Canaday, Peggy C. Yarborough,
described identifies each drug-related problem and states the “Documentation of Pharmacist Interventions” in Instructor’s Guide to
pharmacist’s Findings observed, an Assessment of the findings, the accompany Pharmacotherapy Casebook, 5e
actual or proposed Resolution of the problem based upon the
analysis, and the parameters and timing of follow-up Monitoring.
Either form of note should provide a clear, concise record of
process, activity, and projected follow-up.

 When written for each medication-related problem, these notes

should provide data in a standardized, logical system. In particular,
FARM notes provide a convenient format for progress notes for all
pharmacists, applicable to any practice setting.

21 22
 • THE SUBJECTIVE-OBJECTIVE-ASSESSMENT-PLAN OR SOAP FORMAT WAS ORIGINALLY
DEVELOPED IN THE EARLY 1970’S IN AN ATTEMPT TO STANDARDIZE THE WAY INFORMATION IN

SOAP NOTES WRITING THE MEDICAL RECORD WAS ORGANIZED AND COMMUNICATED.

• IT WAS DEVELOPED BY PHYSICIANS FOR PHYSICIANS, BECAUSE ONLY PHYSICIANS WERE

ALLOWED TO WRITE IN THE MEDICAL RECORD IN MOST US HEALTH CARE INSTITUTIONS AT
THAT TIME.

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• ITS USE AS A WRITTEN COMMUNICATION FORMAT WAS ADOPTED BY OTHER HEALTH CARE
PROFESSIONALS AS THEY INCREASINGLY BEGAN TO USE PROGRESS NOTES AS AN INTER-
PROFESSIONAL COMMUNICATION TOOL, RATHER THAN JUST A RECORD.

• THE SOAP FORMAT IS USED BY PHARMACISTS PRIMARILY TO COMMUNICATE WRITTEN PATIENT

INFORMATION IN THE MEDICAL RECORD.

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 • SUBJECTIVE INFORMATION (THE S IN SOAP) IS PRESENTED FIRST. SUBJECTIVE INFORMATION IS
OBTAINED VERBALLY FROM THE PATIENT OR CAREGIVER AND SO IS NOT DIRECTLY OBSERVED
OR MEASURED BY THE SOAP WRITER.

• OBJECTIVE INFORMATION (THE O IN SOAP) IS PRESENTED NEXT, AND DETAILS DATA DIRECTLY
MEASURED OR OBSERVED BY THE SOAP WRITER OR ANOTHER HEALTH CARE PROFESSIONAL

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• THE SUBJECTIVE AND OBJECTIVE INFORMATION IN A SOAP NOTE SHOULD BE LIMITED TO
ONLY THAT INFORMATION WHICH PERTAINS DIRECTLY TO THE ASSESSMENT OR
RECOMMENDED PLAN.

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 • THE ASSESSMENT SECTION (THE A IN SOAP) OF A SOAP NOTE COMMUNICATES THE CRITICAL
THINKING OF THE WRITER. IF THE WRITER IS A PHYSICIAN, THE ASSESSMENT WILL BE A
DISEASE STATE OR CONDITION DIAGNOSIS AND EXPLAIN WHY THE PHYSICIAN THINKS THAT
THE IDENTIFIED DIAGNOSIS, AND NOT A DIFFERENT DIAGNOSIS, IS CORRECT.

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• IN A PHARMACIST’S SOAP NOTE, THE ASSESSMENT WILL IDENTIFY A DRUG-RELATED PROBLEM • FOR EXAMPLE A SHORTLIST OF THERAPEUTIC ALTERNATIVES WITH A BRIEF EXPLANATION OF
(DRP), AND SHOULD EXPLAIN WHY THE IDENTIFIED DRP NEEDS CORRECTING. BENEFITS AND POTENTIAL PROBLEMS ASSOCIATED WITH EACH OPTION, AND TREATMENT
GOALS COULD BE INCLUDED ALONG WITH AN INDICATION OF THE PRIORITY CHOICE AND
WHY.
• OTHER INFORMATION THAT PHARMACISTS MAY PLACE IN THE ASSESSMENT SECTION IS AN
ASSESSMENT OF THE ACTIONS NEEDED TO ADDRESS THE PROBLEM.
• WHEN WRITTEN OPTIMALLY, BY THE TIME THE READER REACHES THE END OF THE ASSESSMENT
SECTION, THAT READER WILL KNOW EXACTLY WHAT IS GOING TO BE RECOMMENDED, AND
WHY.

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• IF THE PHARMACIST IS ASKED FOR A SPECIFIC CONSULT OR THE PHARMACIST IS TRYING TO
PERSUADE THE READER TO USE A PARTICULAR TREATMENT, EVIDENCE FROM THE MEDICAL
LITERATURE SHOULD BE REFERENCED.

• WHEN THIS OCCURS, IT IS ACCEPTABLE TO FOLLOW THE EVIDENCE PROVIDED BY USING A

BRIEF REFERENCE FORMAT OF ACCEPTABLE JOURNAL NAME ABBREVIATION, YEAR OF
PUBLICATION, VOLUME, AND FIRST PAGE NUMBER.

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• THE FINAL SECTION, WHICH IS THE PLAN, IDENTIFIES THE ACTIONS PROPOSED BY THE WRITER. • WHEN A PHARMACIST MAKES A SPECIFIC CARE SUGGESTION TO A PRIMARY CARE PROVIDER,
WHEN A PHYSICIAN WRITES A PLAN, HE OR SHE IS INDICATING SPECIFIC ACTIONS TO BE THEN THE SECTION IS MORE APTLY TERMED A “RECOMMENDATION.” THUS, PHARMACISTS
CARRIED OUT BY OTHER HEALTH CARE PROVIDERS. WORKING IN AN INTERDISCIPLINARY ENVIRONMENT (HOSPITAL OR CLINIC) MAY MORE OFTEN
WRITE “SOAR” NOTES (SUBJECTIVE-OBJECTIVE-ASSESSMENT-RECOMMENDATION).

• WHEN A PHARMACIST WRITES A PLAN, IT WILL BE IN A SIMILAR MANNER ONLY IF THE

PHARMACIST HAS PRESCRIPTIVE AUTHORITY OR IS IN AN ENVIRONMENT (SUCH AS A
COMMUNITY PHARMACY) WHERE THE PHARMACIST IS THE MAIN HEALTH CARE PROVIDER

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A PHARMACIST’S RECOMMENDATION OR PLAN SHOULD INCLUDE : • SPECIFIC COUNSELING POINTS ABOUT ADMINISTRATION, DOSE, FREQUENCY OF USE, SIDE
• DRUG, DOSE, ROUTE, FREQUENCY, AND DURATION (WHEN APPLICABLE). EFFECTS OR PRECAUTIONS IF THE WRITER’S PURPOSE IS TO DOCUMENT PATIENT COUNSELING.

• WHAT WILL BE MEASURED TO DETERMINE IF THE THERAPY IS WORKING (I.E., EFFECTIVE), WHO WILL • WHEN FOLLOW-UP WILL OCCUR (E.G., FOLLOW UP IN 3 MONTHS FOR REPEAT BP CHECK).
MEASURE IT, HOW FREQUENTLY THIS WILL BE DONE, AND THE GOAL FOR THAT PARAMETER. • THE ALTERNATIVES TO TREATMENT IF EFFICACY IS NOT ACHIEVED OR IF TOXICITY OCCURS.
• WHAT WILL BE MEASURED TO DETERMINE IF THE RECOMMENDED DRUG IS CAUSING A PROBLEM
(I.E., TOXICITY), WHO WILL MEASURE IT, WHEN CONCERN SHOULD ARISE THAT UNWANTED EFFECTS
ARE OCCURRING, AND WHAT WILL BE DONE IF THEY OCCURS. TOXICITY MONITORING WILL
USUALLY INVOLVE DIFFERENT MONITORING PARAMETERS THAN THE EFFICACY MEASURES.

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 WHAT’ ’S WRONG WITH THE FOLLOWING?

• S: MRS. RG IS A 76-YR YR-OLD WOMAN OLD WOMAN WITH 5 GRANDCHILDREN. SHE

COMES WITH 5 GRANDCHILDREN. SHE COMES INTO THE PHARMACY REQUESTING OTC INTO
THE PHARMACY REQUESTING OTC TREATMENT FOR A HISTORY OF TREATMENT FOR A HISTORY
OF OSTEOARTHRITIS X 2YRS. SHE CLAIMS A HISTORY ARTHRITIS X 2YRS. SHE CLAIMS A
HISTORY OF ASPIRIN ALLERGY (GI UPSET). PMH OF ASPIRIN ALLERGY (GI UPSET). PMH
INCLUDES OA, GERD, HBP AND INCLUDES OA, GERD, HBP AND ELEVATED TC

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•(INCLUDES IRRELEVANT INFORMATION (INCLUDES IRRELEVANT INFORMATION -5 5 O: MEDICATION HISTORY INCLUDES NORVASC NORVASC10 MG 10 MG QD FOR BP, NEXIUM 20
GRANDCHILDREN) MG QHS FOR GERD AND PRAVACHOL 20 MG QD FOR ELEVATED TC. CHOLESTEROL FOR
ELEVATED TC. CHOLESTEROL 165 MG/DL AS PER PHYSICIAN OFFICE

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• (HISTORY IS INCOMPLETE INCLUDES ONLY PRESCRIPTION MEDICATIONS FILLED IN THIS • A: DOSE OF APAP TOO LOW FOR OA. PATIENT REQUIRES SYMPTOMATIC PAIN RELIEF FOR OA
PRESCRIPTION MEDICATIONS FILLED IN THIS PHARMACY PAIN. HAS TRIED TYLENOL RELIEF FOR OA PAIN. HAS TRIED TYLENOL 500 MG TID IN PAST
WITH LITTLE RELIEF

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• (INTRODUCES NEW INFORMATION IN THE ASSESSMENT THAT SHOULD BE IN S OR O- USE OF • P: RECOMMENDED PT INCREASE APAP TO 1 G PO QID SCHEDULED DOSE. PATIENT AGREES
TYLENOL

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• MISSING FOLLOW-UP AND MONITORING PLAN)

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