The performance outcomes outlined below provide a guide for successful clerkship completion. All elements may not be applicable to each clerkship setting and should be applied accordingly.

1. Collection of a Pharmaceutical Care Database

The student will collect and record a comprehensive pharmaceutical care database for patients identified in collaboration with the preceptor. The preceptor may identify a set of patients for whom the student must complete the pharmaceutical care database. The student is required to interview the patient and/or caregiver to collect relevant information. The student will review available pharmacy and medical records and communicate directly with other health care professionals (e.g., physicians, nurses, social workers) to obtain additional needed information. In many cases, this may require communication with a local referring physician or other pharmacists in order to obtain a complete database. Appropriate physical assessment will be performed by the student, or results obtained from the appropriate source. The patient database will be an ongoing document; as information is collected it will be recorded in the database.

Acceptable databases should include:

• Source and reliability of information (e.g., patient, caregiver, old chart)
• Patient demographic data, including the patient's identifier, date of birth, sex, and race
• Insurance information (if applicable)
• Chief complaint (if any)
• History of present illness (if patient had a chief complaint)
• Social history; including employment, marital status, home environment, smoking history, alcohol habits, illicit drug use, exercise, and diet.
• Family history, particularly major illnesses of parents, siblings and children.
• Physical findings, particularly those relevant to evaluating drug therapy
• Review of systems (For active health problems and any symptoms related to body systems)
• Pertinent laboratory data (if available)
• Drug history, including:
• Current medications (Rx and OTC; drug, dose, dosage form, regimen, duration)
• Previous drug therapies and reasons for discontinuation
• Adverse drug reaction history and allergy history
• Nontraditional medications or home remedies used
• Name/phone of pharmacy or pharmacies
• Compliance assessment

This database, including the problem list described below, will serve as the student's guide for future decision making.

2. Identify, record, and assess patients' actual and potential drug-related and non-drug-related problems.

The pharmaceutical care database will include a concise problem statement for each of the patient's actual and potential drug-related problems, as well as non-drug problems. The student must assess each problem in terms of its cause, severity, priority in relation to other problems and potential outcomes. This analysis should include an assessment of the patient's adherence to prescribed regimens and recommendations (including exercise and diet). Further, the student must assess the potential for drug-drug, drug-food interactions, adverse drug reactions, and disease exacerbation. Students are expected to integrate patient-specific information with the clinical and basic science knowledge previously learned in the didactic curriculum or by prior clinical experience.

Examples of potential problem areas that should be considered are listed below.

A. Drug Therapy Problems (active and potential)

• a medical diagnosis for which drug therapy is currently being administered (a treated indication)
• untreated indications
• improper drug selection
• subtherapeutic dose
• failure to receive or take drugs
• overdosage
• adverse drug reactions
• drug interactions
• drug use without indications

B. Non-Drug Problems

• medical/health problems
• impact on drug therapy and well-being
• functional impairment (vision, hearing, speech, cognition, prostheses, etc.)
• need for referral to source of care
• mental health problems
• impact on total care
• impact on drug use/misuse
• compliance problems
• to drug and non-drug therapy
• health behavior problems
• health maintenance
• aberrant health care beliefs or medication-taking behaviors
• disease prevention
• accident prevention
• impact on drug therapy and well-being
• social needs/problems
• examples may include financial, housing, transportation, insurance, meals, refrigerator for storage
• impact on drug therapy and well-being
• cultural needs/problems
• examples include language barrier, cultural beliefs, diet, spiritual beliefs, home remedies, etc.
• impact on drug therapy and well-being
• environmental needs/problems
• examples may include lack of refrigeration, indoor plumbing, a telephone, or electricity, and the presence of environmental hazards, etc.
• impact on drug therapy and well-being

**Completion of the pharmaceutical care database and the problem list may be completed using a monitoring form provided by the preceptor or one developed by the student and approved by the preceptor.

3. Develop a Pharmaceutical Care Plan

The student will develop and record a realistic and achievable pharmaceutical care plan for each identified problem.
To be acceptable, the plan must:

• Assess the therapeutic alternatives which may be used to treat the problem.
• Assess the advantages and disadvantages of the therapeutic options, including their comparative efficacy, likelihood of adverse effects, cost,ease of administration, and potential for sub-optimal adherence.
• State the agent(s) dispensed or recommended to treat the problem, including the name, strength, dose, dosing interval, dosage form, and duration.
• Include a detailed monitoring plan for each problem and the treatment regimen, including subjective and objective monitoring parameters used to assess the therapeutic and toxic effect of the patient's medications, and suggested frequency of monitoring. The student is expected to read pharmacy/medical literature to assist in developing pharmaceutical care plans.

The student is expected to provide references from the primary literature in support of care plans where appropriate. Additional readings may be assigned by the preceptor. The format of the patient's pharmaceutical care plan may follow that from a commercially available product as long as the above considerations (A thru D) are included. All care plans must be reviewed and approved by the preceptor prior to implementation.

4. Implement plans.

5. Communicate to the patient and to other health care professionals.

The student regularly present to his/her preceptor the status of patient work-ups as well as general progress in the Clerkship. In addition, the student will provide verbal and written Patient Education and Counseling to each patient (or the caregiver) regarding the appropriate use of medications and devices as a part of the pharmaceutical care plan. The student will communicate orally and in writing with each patient's physician and other health professionals as needed to implement care plans. Whenever possible, the student will communicate the care plan to other pharmacists involved in the patient's care (see 7 below), particularly when the patient undergoes a transition from one care setting to another.

6. Monitor, assess, and document health outcomes.

The student will implement the pharmaceutical care plan, and monitor appropriate indices and therapeutic recommendations. The student will, during the course of therapy and at appropriate time intervals, collect patient data as needed to evaluate whether the intended outcomes of therapy are being met. If the goals are not being met, the student must reassess the problem and take those steps necessary to meet the desired goals. The student will record a progress note after each patient encounter. If a patient experiences an adverse drug reaction, the student will file a report through the FDA MedWatch Program or other recognized adverse drug reaction reporting system.

7. Completion of a Referral Document

When the patient leaves the service of the clerkship, the student should complete a referral document which would/could be forwarded to the next pharmacist who provides follow-up care. This document is similar to the discharge summary completed at a patient's discharge from an inpatient setting. It should summarize the patient's case/situation and describe the therapeutic plan being pursued or the pharmacotherapy plan being implemented. The goals of the plan that require more immediate pharmacist follow-up for optimal continuity should be clearly designated in this document.