Ambulatory Care Pharmacist Patient Workup Template
A comprehensive patient workup template for ambulatory care pharmacists should include structured sections for medication management, medical history, and care planning to optimize patient morbidity, mortality, and quality of life outcomes.
Patient Demographics
- Name, DOB, Age, Gender
- Contact information
- Primary language/interpreter needs
- Insurance information
- Primary care provider and specialists
- Referral source and reason
Chief Complaint/Reason for Visit
- Primary reason for pharmacy consultation
- Patient's stated goals for the visit
- Referring provider's goals for the consultation
Medication Profile
- Current prescription medications (name, strength, directions, start date)
- Over-the-counter medications and supplements
- Medication allergies and reactions
- Medication adherence assessment
- Medication reconciliation findings
- Recent medication changes
- Pharmacy preference and refill history
- Medication storage and administration techniques
- Medication costs/financial concerns
Medical History
- Chronic medical conditions with dates of diagnosis
- Past surgeries and hospitalizations
- Family medical history relevant to medication therapy
- Social history:
Review of Systems
- Targeted symptoms related to medication therapy
- Potential adverse drug reactions
- Disease-specific symptoms (e.g., diabetes, hypertension, heart failure)
Vital Signs and Physical Assessment
- Blood pressure (following proper technique) 1
- Heart rate
- Respiratory rate
- Temperature (if indicated)
- Weight/BMI
- Targeted physical assessment findings relevant to medication therapy
Laboratory and Diagnostic Data
- Recent laboratory values relevant to medication therapy
- Disease-specific monitoring parameters (e.g., A1C, lipid panel, INR) 2
- Diagnostic test results
- Therapeutic drug monitoring results
Medication Therapy Assessment
- Drug-related problems identified
- Drug-drug interactions
- Drug-disease interactions
- Inappropriate dosing or duration
- Therapeutic duplications
- Medication effectiveness evaluation
- Adverse drug reactions or side effects
- Medication adherence barriers
Care Plan
- Medication therapy problems prioritized by clinical importance
- Specific recommendations with rationale
- Monitoring parameters and goals
- Patient education provided
- Follow-up plan and timeline
- Referrals made to other healthcare providers
Documentation of Patient Education
- Medication counseling provided
- Disease state education
- Lifestyle modifications discussed
- Self-monitoring instructions
- Use of teach-back method to confirm understanding 2
- Educational materials provided
Follow-up Plan
- Next appointment scheduling
- Parameters requiring immediate contact
- Communication plan with referring provider
- Specific monitoring responsibilities
Emergency Preparedness
- Emergency medications and equipment available 1
- Emergency protocols and procedures
- Emergency contact information
Pharmacist Authentication
- Pharmacist name and credentials
- Date and time of consultation
- Time spent in direct patient care
- Billing codes (if applicable)
- Collaborative practice agreement reference (if applicable) 3
SOAP Format Documentation Section
Use the SOAP method for structured documentation 4:
- Subjective: Patient's reported symptoms, concerns, and goals
- Objective: Measurable clinical data (vital signs, lab values, physical findings)
- Assessment: Clinical analysis of the patient's condition and medication-related problems
- Plan: Specific recommendations, interventions, education, and follow-up
This template incorporates key elements from clinical guidelines and best practices for ambulatory care pharmacy practice, focusing on comprehensive medication management to improve patient outcomes related to morbidity, mortality, and quality of life.