GUIDELINES FOR PHARMACY. Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 1

Transcription

1 PHARMACEUTICAL SERVICES DIVISION MINISTRY OF HEALTH MALAYSIA GUIDELINES FOR INPATIENT PHARMACY PRACTICE Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 1

2 MINISTRY OF HEALTH MALAYSIA First Print, 2010 Pharmaceutical Services Division, Ministry of Health, Malaysia. ALL RIGHTS RESERVED No part of this publication may be reproduced, stored or transmitted in any form or by any means whether electronic, mechanical, photocopying, tape recording or others without written permission from the Senior Director of Pharmaceutical Services, Ministry of Health, Malaysia. Perpustakaan Negara Malaysia Guidelines for Inpatient Pharmacy Practice, Ministry of Health Malaysia. ISBN Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia

3 PREFACE Director Pharmacy Practice and Development Division Ministry Of Health Malaysia Pharmacy Practice and Development Division has been evolving and this is evidenced through years of excellence in performance. Primarily focussed on patient safety, we are responsible for the optimisation of drug therapy and prevention of medication errors. Throughout the expansion of services, Pharmacy Practice and Development Division has introduced standardisation of procedures towards assisting proper management of Drug Distribution and Ward Pharmacy activities. This Guidelines for Inpatient Pharmacy Practice will serve as a tool for all to work conscientiously for the benefit of patients. This guideline focuses on good management of drug distribution describes work flows of the Inpatient Pharmacy processes and explanation of the necessary documents involved. It is hoped that the guidelines are able to steer good management practice in conducive environments towards fulfilment of customers' needs. I would like to convey my gratitude to the Clinical & Technical Pharmacy Working Committee in the success of producing this guideline. Also, a special thanks to all parties that contributed during all stages of development and publication of this guideline. Thank you Hasnah binti Ismail Director, Pharmacy Practice and Development Division, Ministry of Health Malaysia. Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 3

4 Table of Contents Page Preface 3 Table of Contents 4 Editorial Board Inpatient Pharmacy Services Drug Distribution Activities Unit Dose System Floor Stock / Emergency Trolley Medications After Office Hours Supply Supply of Psychotropic Medicines Supplies for Discharged Patients Handling Referral Letter (Second Copy) and Supply of Medications for Patients being referred to Health Facilities Ward / Unit Medication Inspection Ward Pharmacy Activities Medication History Taking Case Clerking Pharmacotherapy Rounds Medication Review Medication Reconciliation Medication Counselling Discharge Planning Other Activities 4.1 Clinical Pharmacokinetic Service Drug Information Service Adverse Drug Reaction Monitoring and Reporting Medication Error Reporting Product Complaint Reporting Processing Request for Non-Formulary Medications Documentations Reference Appendices Glossary 67 4 Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia

5 Editorial Board Advisors Eisah A Rahman Senior Director of Pharmaceutical Services, Ministry of Health Malaysia Hasnah Ismail Director of Pharmacy Practice and Development Pharmaceutical Services Divison, MOH Editors Abida Haq Syed M. Haq Deputy Director Pharmaceutical Services Division, MOH Ainul Salhani Abdul Rahman Principal Assistant Director Pharmaceutical Services Division, MOH Rabi'ah Mamat Principal Assistant Director Pharmaceutical Services Division, MOH Phuar Hsiao Ling Senior Assistant Director Pharmaceutical Services Division, MOH Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 5

6 6 Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia

7 GUIDELINES FOR INP ATIENT PHARMA CY INPA PHARMAC PRACTICE PRA CTICE Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 7

8 8 Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia

9 Inpatient Pharmacy Services INPATIENT PHARMACY SERVICES Pharmaceutical care is an area in the health care system which has yet to be fully developed in Malaysia although it has generated tremendous impact worldwide. Since its inception in the 1990's, Malaysian pharmacists have embarked on a bold and dramatic leap forward to embrace its philosophy in all areas of pharmaceutical care services. Much effort has been put into exploring ways in which to instil and initiate pharmaceutical care activities in both the outpatient and inpatient settings. Inpatient Pharmacy Services Ward pharmacy activities encompass issues on all aspects of pharmacotherapy. During ward rounds, input pertaining to appropriateness of therapy, counselling of patients on medication therapy and the monitoring of unwanted side effects are the major services provided. Often time, the input given is not documented. Thus, a mechanism to document these activities is crucial and urgently required. The pharmaceutical needs of a patient refer to his or her requirements for pharmaceutical products or services. Pharmaceutical needs may be identified by any member of the health care team or by the patient him/herself. Once a targeted patient group has been assigned to the responsibility of a clinical pharmacist, a function of the delivery of the service is to prioritise the individual patient in the group according to his/her potential pharmaceutical care issues (PCI). It is important to document the outcomes of the pharmaceutical care intervention for the purpose of individual patient records as well as information for the management. Information on issues such as drug availability, dosage form, procurement and storage should be managed in liaison with colleagues in other units. Pharmacists require both knowledge and clinical experience to be a useful member of the health care team. Therefore the clinical pharmacist serves as a liaison person between patients, doctors, nurses and fellow pharmacists. Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 9

10 2.0 Drug Distribution Activities 2.0 DRUG DISTRIBUTION ACTIVITIES Objectives Drug Distribution Activities The pharmacy department should implement a distribution system that meets the following objectives: i. To dispense prescribed drugs to patients in wards in a timely and efficient manner ii. To avoid occurence of medication error iii. iv. To minimise drug wastage To minimise opportunities for drug diversion v. To maintain information on drug utilization and rational drug use vi. To identify unusual patterns of drug usage Drug Distribution Method Currently, three types of drug distribution systems are being practiced i.e. the traditional system, unit-of-use system and unit dose system. The unit dose system (UDS) should be encouraged due to its many advantages. The UDS involves dispensing of drugs to individual patients on a daily basis and for 24 hour duration only. The unitof-use system (UoU) is similar to UDS in many ways except to the duration of supply. Drug distribution system may be centralised or decentralised depending on location and facility itself. Other activities include: i. Floor Stock / Emergency Trolleys Medication ii. iii. iv. After Office Hours Supply Supply For Psychotropic Medicines Supplies For Discharged Patients v. Ward / Unit Inspection 2.1 UNIT DOSE SYSTEM All medications dispensed to patients in the wards should be kept in individually labelled drawers or trays in the medication trolleys for patients. The amount of medication dispensed should be according to the dosage regimen and placed in compartments within the patient drawers. The medication trolley must be lockable and the keys kept by a registered nurse in the specific ward and another by an authorised pharmacy staff. 10 Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia

11 Drug Distribution Activities Handling of Medication Trolley 1. The medication trolley should be sent to the pharmacy by the nurse on duty for the supply of new prescriptions and daily refilling of current prescriptions after dose administration times, usually at 8.00am. 2. The trolley has to be collected by ward staff before the next dose administration time at noon Medication Order 1. The medication order for ward patients must be completed in the self-carbonised Medication Chart and signed by the prescriber according to the categories set by the Ministry of Health Malaysia Drug Formulary (FUKKM). Drug Distribution Activities 2. Each prescription must be written with the generic name, complete with dose in mg, ml or IU; administration route such as SC, IM, IV, PO, LA or others; administration frequency such as DAILY, BD, TDS, QID etc; treatment duration such as 5/7, 1/52 or 2/52; starting date; prescriber's signature; patient name and ward/bed number. 3. All prescriptions of medications for A, A/KK or A* categories must be stamped and countersigned by the relevant specialist. Controlled medicines must be attached with application forms according to the practice in individual institutions. 4. All original prescriptions (white) from the Medication Chart should be separated from the carbonised copy (yellow) (Appendix 1). The carbonised copy should be retained in the ward. 5. A new medication order (prescription) must be made in the following situations: a) Newly-admitted patients b) Patients transferred in from other wards c) Patients who have just undergone an operation or special procedures d) Expired prescriptions but treatment needs to be continued 6. For patients who have just been admitted into the ward, the prescription has to be sent with the patient's Cumulative Medication Record (Appendix 2). 7. For patients currently in the ward, any addition of medications must be made through a prescription. Any changes in dose, dosage form, frequency or treatment duration warrants a new prescription attached with an Advice Note (Appendix 3). Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 11

12 2.0 Drug Distribution Activities 8. The completed original prescription must be separated from the self-carbonised copy, collected and sent to the pharmacy. Drug Distribution Activities 9. The nurse on duty is responsible for sending prescriptions for all patients in the ward to the pharmacy. Under certain circumstances, the nurse can direct the Penolong Perawatan Kesihatan (PPK) to send the prescriptions to the pharmacy Receiving the Prescription 1. All prescriptions received must be checked by the Pharmacist/ Pharmacy Assistant to ensure that they are complete. 2. Screening of all prescriptions should be done by the pharmacist to ensure the following: a) Authenticity of prescription/prescriber b) Adherence to FUKKM c) Suitability of dosing regimen d) Drug interactions e) Polypharmacy f) Correct medication administration method and frequency g) Others 3. For any other interventions, the Pharmacist/ Pharmacy Assistant should either contact the medical officer concerned for clarification or issue an Intervention Note (Appendix 4). 4. Any changes made to the prescription can only be made with the prior consent of the prescriber concerned and recorded into the 'Notes' column of the CMR. If the countersignature for Category A medications has not been obtained, the prescription should be copied into the CMR and the medication supplied first while waiting for the countersignature. The Intervention Note that states the necessity for the specialist's signature should be sent to the ward with the prescription. After it is signed, the prescription will be returned to the pharmacy to be pasted on the CMR. 12 Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia

13 Drug Distribution Activities All new prescriptions which have been screened should be pasted on the patient's CMR and the expiry date of the prescription recorded in the amount column. For example: MEDICATION RECORD Date Amount Date Amount NOTES PATIENT'S NAME C16-B2 Ooi Chooi Seng DRUG Tab. Allopurinol 300mg Date Start 12/10/09 Prescriber's signature & stamp 12/10/09 1 x 1 Drug Distribution Activities Dose 1/1 Route PO Frequency Duration Daily 7/7 6. To discontinue a medication, the prescription at the CMR must be stamped with "UBAT DIBERHENTIKAN". At the Medication Chart (yellow copy) in the ward, the prescriber/pharmacist/nurse can record the discontinuation of the medication in the yellow copy. 7. To withhold medication, it must be recorded as "WH" in the CMR at the amount column. The same should be done for the Medication Chart in the ward, which should be done by the doctor/ pharmacist/ nurse. 8. Changes in medication dose or administration frequency need to be stamped with "RUJUK PRESKRIPSI BARU" Filling of Prescriptions 1. All medications supplied to the ward must be in ready-to-use form in a container meant for administration of one dose and not exceeding the requirements for 24 hours. 2. Filling of prescription should be done by the Pharmacist/ Pharmacy Assistant and counterchecked by another Pharmacist. 3. Filling has to be done for new prescriptions and current prescriptions in the CMR. Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 13

14 2.0 Drug Distribution Activities 4. Amount of medication and frequency supplied for the day should be written in the 'Amount' column of the CMR. [For example, Paracetamol 1g (2 tablets) QID will be recorded as 2 x 4 as below]: Drug Distribution Activities DATE AMOUNT DATE AMOUNT DATE AMOUNT NOTES 12/10/09 2 X 4 5. Pharmacy staff has to ensure the cleanliness of the medication trolley and bins. All bins must be emptied before filling is done. 6. If there is a balance of medication in the patient's bin and no Advice Note is given, explanation from the nurse on duty in the ward concerned has to be obtained and recorded in the CMR. 7. One bin is allotted per patient. Each bin must be filled with the medication prescribed, with the correct quantity based on the CMR and in accordance with the administration times. Examples of administration times are as follows: Frequency Time 4 hourly 6 am, 10 am, 2 pm, 6 pm, 10 pm, 2 am QID TDS BD ON OM Before meal Before meal BD prn 6 am, 12 noon, 6 pm, 10 pm 8 am, 2 pm, 8 pm 8 am, 8 pm 10 pm 8 am 6 am 6 am (before breakfast), 6 pm (before dinner) Placed at the furthest end of the patient's bin. 14 Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia

15 Drug Distribution Activities For the dispensing of medications such as eye/ear drop solutions or creams, the total volume or weight supplied must be recorded in the "amount" column and stamped with "TELAH DIBEKAL PADA". For example: DATE AMOUNT DATE AMOUNT DATE AMOUNT NOTES 12/10/09 1 x 5ml atau 1 x 30g TELAH DIBEKAL PADA Drug Distribution Activities 9. Filling of prescriptions involving psychotropic medications, exchange basis drugs and floor stock items need not be done in a unit dose manner and the prescription should be stamped with EXCHANGE BASIS, USE PSYCHOTROPIC STOCK or USE FLOOR STOCK. 10. Use the "SELESAI" stamp after the prescriptions have been supplied in full. 11. For prescriptions where dosage forms of the medication are changed from injection to oral, the CHANGE TO ORAL stamp should be used and vice versa. 12. For PRN doses, the medications are placed at the back of the individual bin. On the first day, the amount of doses supplied should be recorded and for subsequent days, only the amount of doses added needs to be recorded. Example 1: Tab. Paracetamol 1g PRN. DATE AMOUNT 12/10/ /10/ /14/09 +2 Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 15

16 2.0 Drug Distribution Activities Example 2: Tab. Chlorpheniramine 4mg TDS & PRN DATE AMOUNT 12/10/09 1 x Drug Distribution Activities 13/10/09 1 x (not added) 14/14/09 1 x The staffs filling the bins have to sign the Unit Dose Dispensing Checklist (Appendix 5) Checking the Supply (Countercheck) 1. All unit dose medication supply must be counterchecked by a different pharmacy staff from the one who did the filling. 2. All medication filling and counterchecking process must be done before the trolley collection time at noon. 3. The nurse on duty should check the supply received and inform the pharmacy if there are any discrepancies. 4. After checking the supply, the nurse on duty should receive the medication trolley and acknowledge receipt in a form according to the requirements of individual hospitals 5. All the filling errors need to be corrected and recorded for the purpose of QAP Monitoring. 2.2 FLOOR STOCK / EMERGENCY TROLLEY MEDICATIONS Wards are only permitted to keep a limited quantity of frequently-used medications. A medication list which has been agreed upon by the pharmacy and the ward / unit should be kept in the ward / unit and pharmacy. Level of floor stock / emergency trolley items should be more than the minimum limit but should not exceed the maximum limit. Floor stock / emergency trolley medication list should be reviewed periodically. 16 Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia

17 Drug Distribution Activities 2.0 The procedures for supplying Floor Stock / Emergency Trolley Medications are as follow: 1. Receive medication order book from the ward / unit 2. Check balance of floor stock / emergency trolley medications 3. Record the quantity supplied in the order book 4. Supply medication according to the recorded quantity 5. File the original copy of the order book 2.3 AFTER OFFICE HOURS SUPPLY Drug Distribution Activities Drugs prescribed after normal working hours will be supplied according to the amount requested to the pharmacy staff on-call. 2.4 SUPPLY OF PSYCHOTROPIC MEDICINES Wards may only keep psychotropic medicines in the amount permitted in a medication list. A copy of the medication list as agreed upon by the pharmacy and the ward / unit should be kept in the ward / unit and pharmacy. Record books must be updated each time psychotropic medications are used based on valid prescription (order form). The procedures for supply of psychotropic medicines are as follow: 1. Receive order form and psychotropic medications record book from the ward / unit. 2. Check order form and record of psychotropic medication use 3. Determine that the order is consistent with use and record the balance of psychotropic medications 4. Record supply in the psychotropic medications register book 5. Record the quantity supplied and sign the psychotropic medications record book and order form 2.5 SUPPLIES FOR DISCHARGED PATIENTS Supplies for discharged patients should follow the same procedures as that of dispensing at the counter. However for medication counselling (refer Chapter 3.5) and bedside dispensing (refer Chapter 3.6), should ideally be carried out for the following category of patients: Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 17

18 2.0 Drug Distribution Activities Drug Distribution Activities 1. Patients using devices (inhalers, insulin pen); to reinstate what has been taught during ward stay. 2. Patients with several debilitating conditions who are on many different medications. 3. Patients newly diagnosed with chronic illnesses 4. Patients on medications with narrow therapeutic index. 5. Patients who have poor understanding/knowledge/comprehension of medication usage / regimen 2.6 HANDLING REFERRAL LETTER (SECOND COPY) AND SUPPLY OF MEDICATIONS FOR PATIENTS BEING REFERRED TO HEALTH FACILITIES The policy of Ministry of Health Malaysia stated that stable patients can be referred to nearby health facilities (hospital or health clinic) by using referral letter, for the purpose of continuing treatment. Proper handling of referral letter (second copy) and supply of medications to referred patients are important since not all facilities keep certain medicines. Pharmacy Department is responsible in ensuring that there is a policy/ procedure regarding the submission of referral letter (second copy) to Pharmacist at the facility where the patient is referred to. Objectives of proper handling of referral letter: To ensure preparedness of medications at the referred facility To ensure continuity of treatment Referring patient by referring facility 1. The Medical Officer will fill in three copies of the referral letter (Appendix 6). The first copy is for the patient to bring to the referred facility The second copy is to be given to the Pharmacist at the referring facility The third copy is to be kept in patient file at the referring facility 2. Pharmacist at the referring facility will review the patient's drug regiment with the Pharmacist at the referred facility If the referred facility does not keep the medicines, the referring facility must supply enough medication until the next appointment date at the referred facility 18 Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia

19 Ward Pharmacy Activities 3.0 Both Pharmacists should also discuss the patient's next supply of medications 3. Pharmacist at the referring facility must fax or post the second copy of the referral letter to the Pharmacist at the referred facility, and if necessary supply the medications to the referred facility before the next appointment date 4. A copy of the second copy of the referral letter should be filed for reference purposes Receiving Second Copy at referred facility Drug Distribution Activities 1. Inform the referring facility upon receiving the second copy (and supplied medications from the referring facility if necessary) 2. Review patient's drug regiment (and supplied medications from the referring facility if necessary) 3. Register the patient's particulars into the Drug Supply Registry Book (Appendix 7) 4. File the second copy of the referral letter 5. Dispense medications on the fixed appointment date 2.7 WARD / UNIT INSPECTION Ward Inspection is done to ensure the following: a. Ward stocks comply with the amount approved b. Expiry dates of all drugs are clearly labelled c. Drugs are properly labelled d. Drugs are properly stored e. Emergency drugs are available and in good order f. Medication trolleys are checked regularly g. Refrigerated items are stored appropriately h. Psychotropic drugs are used, stored and recorded according to the requirements of existing laws Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 19

20 2.0 Drug Distribution Activities Criteria for Good Drug Distribution Service Implementing the Unit Dose System Appropriate storage of Ward Stock Drug Distribution Activities Adequate Floor Stock level Complete range of Emergency Drugs Access to after office hours supply Routine Ward / Unit Inspection 20 Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia

21 Ward Pharmacy Activities WARD PHARMACY ACTIVITIES Ward Pharmacy activities should be in line with the concept of Pharmaceutical Care i.e. patient-centred, outcomes-oriented pharmacy practice. It requires the pharmacist to work in concert with other healthcare providers to promote health, to prevent disease, and to assess, monitor, initiate and modify medication towards ensuring that drug therapy regimens are safe and effective. The goal of ward pharmacy activities is to optimise the patient's pharmacotherapy and achieve positive clinical outcomes within realistic economic expenditures. Four types of forms are designed to document ward pharmacy activities:- i. Medication History Assessment Form (CP1) ii. iii. iv. Pharmacotherapy Review (CP2) Clinical Pharmacy Report Form (CP3) and Discharge Referral Note (CP4) Ward Pharmacy Activities Ward pharmacy activities include the following: i. Medication History Taking ii. iii. iv. Case Clerking Pharmacotherapy Rounds (including routine rounds, pharmacists' rounds and grand ward rounds) Medication Reviewing v. Medication Reconciliation vi. Medication Counselling vii. Discharge Planning Tips to Achieve Pharmaceutical Care Goals Establish and maintain professional relationships with patients and other healthcare team members. Collect, organise, record and maintain patient-specific medical information. Evaluate patient-specific medical information and develop good rapport with patients. Ensure that the patient has all supplies, information and knowledge necessary to carry out the drug therapy plan. Review, monitor and modify therapeutic plan when necessary and in concert with the patient and healthcare team. Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 21

22 3.0 Ward Pharmacy Activities 3.1 MEDICATION HISTORY TAKING Medication history taking by pharmacists is essential for retrieving missing information with regard to prescription medications which the patient is currently on, information on past drug history as well as self-medication. This additional information can be an invaluable aid for pharmacists and other healthcare providers in assessing and determining the best treatment options towards optimising patient care. Ward Pharmacy Activities Objectives of medication history taking: To gauge the patient's understanding towards their medications To ensure continuity of medication treatment To elucidate information on non-compliance towards drug treatment To ascertain if patients are taking other forms of medications such as supplements, over-the-counter (OTC) medicines and herbal preparations. The Medication History Assessment Form (CP1) should be used as a guide for effective medicine history taking. The form should be kept with the patient's case notes to serve as a reference for other healthcare providers. Important Points for Effective Medication History Taking 3.4 List MEDICATION all current medications, REVIEWING including self-prescribed medication supplements and herbal preparations with dosages and dates of commencement. Medication orders should be reviewed for incomplete prescriptions, inappropriate drug use, Write unclear down instructions, the medication authenticity history of previous of the treatment prescriber, that administration may be relevant errors, to the present appropriate treatment drug storage and any and reason other for issues changes related or alterations to patient's in the regimen. drug management in the ward to determine the pharmacotherapeutic appropriateness of each order for the individual patient. Note history of allergy or adverse drug reactions to any particular drug / food. 3.5 Assess MEDICATION compliance. RECONCILIATION Record any problem related to medications (e.g.: storage, supply, containers, labelling etc). 3.2 CASE CLERKING Case clerking and medication review are often done concurrently. Most PCIs and potential pharmaceutical interventions are identified during these two activities. Pharmacists should play an active role in recognising these issues and documenting them into the case notes. If the PCI is significant to the patient's current medication plan, the issue should be highlighted to other healthcare providers during ward rounds or wherever necessary. Efficient case clerking and reviewing require skills to keep pharmacists focused on the active pharmaceutical care plans and interventions. 22 Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia

23 Ward Pharmacy Activities 3.0 Case clerking should be done for all new admissions as far as possible. The subsequent revision of the case is known as case reviewing. Recurrent admissions should be treated as new admissions, thus requiring new case clerking to be performed. All findings, suggestions and interventions performed pertaining to PCIs during case clerking / reviewing should be documented in the Pharmacotherapy Review Form (CP2) for continuous follow-up to achieve targeted pharmaceutical outcomes. Once the form is completed, the case should be reviewed and updated on a daily basis until the patient is discharged. Patient's progress should be monitored by analysing objective and subjective parameters, updating current pharmaceutical care issues and intervening accordingly when necessary. Skills for Efficient Case Clerking Able to extract relevant information from medication chart, case notes, laboratory data, Medication History Assessment Form and relevant details from patient interview Identify PCI Ward Pharmacy Activities Analyse relevant data according to specific pharmaceutical care issues (PCI) Differentiate PCIs from physician's management plan Possess relevant clinical knowledge Analyse relevant laboratory results Summarise clinical findings 3.3 PHARMACOTHERAPY ROUNDS Active participation in ward rounds requires good rapport with other healthcare teams, up to date knowledge on drugs and information on drug availability and dosage forms. The following 4P easy steps should be adapted to get started: Prepare, Participate, Perform and Prove. Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 23