Chapter 2

The Medical Record

Linda M. Spooner, PharmD, BCPS
Kimberly A. Pesaturo, PharmD, BCPS

Learning Objectives
• Explain the importance of being proficient in navigating a patient’s medical record.
• Outline the general components of a patient medical record.
• Describe paper-based and electronic medical records.
• Describe a systematic method for collecting information from a patient’s medical
record for the purpose of developing an assessment and plan.
• Identify and define key pharmacy-related components within a patient’s medical history
and physical examination.
• Synthesize patient information to develop a comprehensive problem list, including drug-
related problems.

Key terms
• Drug-related problems
• History and physical (H&P)
• Problem list

intrOductiOn
As pharmacists continue to increase their involvement in patient care activities,
their ability to navigate the often murky waters of the medical record becomes
even more crucial. Locating vital pieces of information is critical to developing an
appropriate assessment and plan for the individual patient. Additionally,
collecting
38 chapter 2 / the medical record

this data in a systematic way will permit the pharmacist to then synthesize it and
create a comprehensive list of healthcare needs and considerations for the patient,
regardless of the practice setting.

impOrtance Of prOficiency in navigating

the patient’s medicaL recOrd
It can be extremely overwhelming to think about the vast quantities of medical
infor- mation every person has accumulated over a lifetime. Even the amount of
documenta- tion required during a hospital stay can be quite lengthy, which can
make it difficult to locate specific data critical to drug therapy selection and
assessment of patient response. Compounding these issues is the fact that every
institution and clinic has a different method for organizing patients’ medical
information.
Because most encounters with patients occur over more than one point in
time, the use of a medical record facilitates the documentation of all data
collected over time. In both the hospital and clinic settings, the medical record
takes the form of a patient chart composed of printed materials in a folder or
binder (paper-based chart) or within a computer system (electronic medical
record), or a combination of the two. Regardless of the system used by an
institution or clinic, the general order of the medical record is similar, as shown in
table 2.1. Depending upon the indi- vidual patient’s characteristics, the
inpatient medical record can be quite lengthy, especially when there are
numerous comorbidities or complications that require a long hospitalization.
Similarly, the outpatient medical record can become exten- sive when a patient
has had numerous encounters with the practitioner over many years’ time.
Developing familiarity with where to find vital pieces of information makes the
development of an assessment and plan more efficient and effective. The first
step is understanding the contents contained within each component of the
medical record.

cOmpOnents Of a patient’s medicaL recOrd

The medical record can be dissected into five primary components, including
the medical history (often known as the history and physical, or h&p),
laboratory and diagnostic test results, the problem list, clinical notes, and
treatment notes.1,2 Subheadings for each component are located in Table 2.1. It
is important to note that although physicians and other prescribers may use
this format as a method for their documentation pharmacists may use different
formats for their own records.
 components of a patient’s medical record 39

tabLe 2.1 components of a patient’s medical record

Medical history (also known as history and physical, or H&P)

• Patient demographics

• Chief complaint (CC)

• History of present illness (HPI)

• Past medical history (PMH)

• Family history (FH)

• Social history (SH)

• Allergies

• Medication history

• Review of systems (ROS)

• Physical examination (PE)

Laboratory test results

Diagnostic test results

Problem list

Clinical notes

• Progress notes

• Consultation notes

• Off-service notes/transfer notes

• Discharge summary

Treatment notes

• Medication orders

• Surgical procedure documentation

• Radiation treatments

• Notes from ancillary practitioners

40 chapter 2 / the medical record

medical history
The medical history, or H&P, includes the following components:
• patient demographics. This section includes the patient’s name, birth date,
address, phone number, gender, race, and marital status and the name of
the attending physician. This section may also include the patient’s insurance
infor- mation, pharmacy name and phone number, and religious
preference.
• Chief complaint (CC). The chief complaint is the primary reason the
patient is presenting for care. Often expressed using the patient’s own words,
it includes the symptoms the patient is currently experiencing. At times the
CC is not really a “complaint” at all; the patient may be presenting to the
pharmacy to have a prescription filled or may be coming to the clinic for
an annual physical exam.
• history of present illness (hpI). The history of present illness expands
upon the CC, filling in the details regarding the issue at hand. The HPI is
typically documented in chronological order, describing the patient’s
symptoms in detail as well as documenting related information regarding
previous treatment for the CC, previous diagnostic test results, and
pertinent family and social history. Additionally, pertinent negative
findings are located in the HPI; these include symptoms the patient is not
currently experiencing that provide more informa- tion on the case (e.g., a
patient presenting with vomiting who notes that he does not have
abdominal discomfort).
• past medical history (pMh). The past medical history includes a list of
past and current medical conditions. Past surgical history (PSH) is often
included within the PMH, as are previous hospitalizations, trauma, and
obstetrical history (for female patients).
• Family history (Fh). The family history includes descriptions of the age,
sta- tus (dead or alive), and presence or absence of chronic medical
conditions in the patient’s parents, siblings, and children.
• Social history (Sh). This section includes a large amount of information
regarding the patient’s lifestyle and personal characteristics, including the
patient’s use of alcohol, tobacco, and illicit drug use, each documented as
type, amount, frequency, and duration of use. The social history also
includes descriptions of the patient’s dietary habits, exercise routine, and
use of caf- feine as well as years of education, occupation, marital status,
number of children, sexual practices and preferences, military history, and
current living conditions.
 components of a patient’s medical record 41

• allergies. Although some H&Ps include allergy information in a general

“medication history” section, many medical records provide a separate
head- ing to denote any history of allergic reactions a patient has had to
medications, foods, vaccines, stings, and contrast media, as well as what
type of hypersen- sitivity reaction occurs when a patient is exposed to the
agent, including rash, hives, or anaphylaxis.
• Medication history. Information regarding the patient’s current
medication list may be found in several areas of the inpatient chart,
including a resident’s initial H&P, the medication reconciliation form, and
nursing intake notes. Reviewing each of these areas may be necessary to
gather a complete list of current medications (prescription,
nonprescription, and complementary and alternative medicines), dosages,
frequency of administration, duration of therapy, reason for taking, and
adherence.
• review of systems (rOS). The review of systems portion of the H&P pro-
vides information regarding the subjective feelings, or symptoms, the patient is
experiencing. Conducted in head-to-toe order, positive findings and
pertinent negative responses are documented overall and for each organ
system. This information is in addition to those ROS located within the
CC and the HPI. The usual order of ROS is provided in table 2.2.
• physical examination (pe). The physical examination contains
objective information obtained from the practitioner’s examination of the
patient. As mentioned previously, subjective information is typically excluded
from the PE, allowing for inclusion of information gathered by the practitioner
upon observ- ing and touching the patient. Like the ROS, the PE is
documented in a head- to-toe format, permitting straightforward review
of all organ systems. One of the most common sequences is listed in table
2.3.

Laboratory test results

Initial laboratory results are documented following the initial H&P. Most patients
will have a basic metabolic panel and complete blood count (CBC) in addition to
other parameters specific to their diagnosis and medical conditions, including,
but not limited to, cardiac enzymes, serum drug concentrations, international
normalized ratio (INR), liver function tests, and cultures of blood or other body
fluids. Calculated values, such as anion gap and creatinine clearance, are also
documented in this section. Computer systems are commonly used to collect and
manage laboratory test results. Occasionally, results may be printed and placed
in the paper medical chart;
42 chapter 2 / the medical record

tabLe 2.2 Order and contents of review of systems

body system examples of contents

General Overall feelings of wellness, weight gain or loss, fever, chills,

night sweats, fatigue, weakness

Skin Changes in color, dryness, hair loss, rashes, pruritis, bruising,

bleeding

Head Headaches, trauma, syncope

Eyes Change in vision (blurry vision, double vision, floaters), trauma,

use of corrective lenses

Ears Change in hearing, tinnitus, vertigo, pain

Nose Discharge, stuffiness, epistaxis

Mouth Soreness, gum bleeding, issues with teeth

Throat Difficulty swallowing, painful swallowing, change in voice

Neck Pain, stiffness, swelling, lumps

Respiratory system Shortness of breath, dyspnea, wheezing, cough (dry vs. produc-
tive), orthopnea, hemoptysis

Cardiovascular system Chest pain, palpitations

Gastrointestinal system Nausea, vomiting, constipation, diarrhea, abdominal pain,

hematemesis, melena, hematochezia, jaundice

Genitourinary system Urinary frequency, urgency, hesitancy, dysuria, hematuria,

incontinence, pain

Females: Vaginal discharge, discomfort, itching, character of

menstrual periods, contraceptive method

Males: Erectile dysfunction, lesions, contraceptive method

Nervous system Seizures, tremors, weakness, altered sensations, difficulties in

speech, incoordination

Musculoskeletal system Pain, trauma, tenderness, swelling, decreased range of motion

Neuropsychiatric system Changes in mood (anxiety, depression), changes in memory,

difficulty sleeping, difficulty concentrating

Endocrine system Polyuria, polydipsia, polyphagia, intolerance to heat or cold

Peripheral vascular system Varicose veins, leg cramping, edema

 components of a patient’s medical record 43

tabLe 2.3 sequence of the physical examination

• Vital signs

• General appearance

• Head, eyes, ears, nose, and throat (HEENT)

• Neck

• Chest (lungs and breasts)

• Heart

• Abdomen

• Genitourinary system

• Rectal examination

• Extremities

• Lymph nodes

• Neurologic examination

• Skin

however, the most current and complete results are usually located in a
computer database. Additionally, practitioners’ H&Ps may include documentation of
initial lab results. However, it is important to view the actual results for oneself,
because it is easy for an error in transcription to occur. Similarly, practitioners
may omit some results from the H&P documentation for the sake of brevity;
again, viewing actual results on a computer system will permit a complete
review of data.

diagnostic test results

Initial results of diagnostic testing are documented within the H&P as well. Such
results may include electrocardiograms, echocardiograms, ultrasounds, computed
tomography (CT) scans, magnetic resonance imaging (MRI) scans, x-rays, and so
on. Because these tests require interpretation, often by a separate physician (e.g.,
radiologist, cardiologist), dictations of their results are often available on a
computer system and/or may be printed for placement in the paper chart.
44 chapter 2 / the medical record

problem List
The problem list notes, in decreasing order of priority, the issues that require
man- agement in the individual patient. The number one need on the list is the
working diagnosis that matches the signs and symptoms with which the patient has
presented. For example, a patient presenting with chest pain who is diagnosed
with a ST segment elevation myocardial infarction will have “STEMI” listed as
the healthcare need of highest priority on the list. Alternatively, a patient
presenting to a community phar- macy with a prescription for an
antihypertensive medication for newly diagnosed hypertension may have “initial
treatment for HTN” as the number one need on the list. Subsequent healthcare
needs or problems are listed in descending order of prior- ity or severity; these
typically include chronic medical conditions contained within the PMH, abuse of
substances noted in the social history, drug-related problems identified with current
or past medications, laboratory or diagnostic test abnormalities identified upon
admission, and so on.
Numerous practitioners will document problem lists within the medical
record. For an inpatient, the admitting practitioner, nurse, pharmacist,
nutritionist, respira- tory therapist, and physical therapist may each have their own
prioritized list of needs within the chart, overlapping in some ways and unique in
others. From these, it is possible to create a comprehensive list that addresses all
of the issues at hand. For an outpatient, the attending practitioner may develop a
list at the end of his or her note, addressing those issues of highest priority. For
both inpatients and outpatients, prac- titioners will often document their plans
for each need, including a differential diag- nosis, treatments being considered or
administered, and a plan for patient education. Regardless of location, it is
important to note that the problem list is dynamic.
It can change from day to day for an inpatient or from visit to visit for an outpa-
tient. This is anticipated because patients’ diagnoses and individual characteristics
can change quickly, especially in the acute setting. Later in this chapter we will
review how to develop a comprehensive problem list that includes drug-related
problems.

clinical notes
The inpatient paper chart often gets thick with the many types of clinical notes
writ- ten by the numerous practitioners caring for the patient. The resident and
attending physician will write daily progress notes that document an updated
and abbreviated H&P, problem list, and plan. Other specialists (e.g., cardiologist,
gastroenterologist) will also document their findings in daily progress notes
following their initial consul- tation notes. For example, a patient with a history of
atrial fibrillation and coronary
 components of a patient’s medical record 45

artery disease may have a cardiologist following his case; the impressions of this
spe- cialist are communicated to the patient care team via daily progress notes
focusing on the patient’s cardiac issues.
Nurses maintain their own clinical notes within the computer system or on a
bed- side chart. Often these include documentation of vital signs, pain assessments,
patient activities (e.g., out of bed to chair, bathroom visits), and quantity of fluid a
patient ingests and excretes (e.g., ins and outs). Additionally, if there is a change
in care, such as movement from the intensive care unit (ICU) to the general
medical floor, transfer notes are written by the physicians and nurses to smooth
the transition between care teams. Similarly, if a practitioner is no longer going to
care for a patient, for example, due to a vacation or time away from the hospital,
he or she will write an off-service note to assist the successor practitioner in the
transition of care. All of these notes are useful summaries of the diagnostic methods
used and treatment provided prior to the occurrence of the transfer.
Lastly, a discharge summary provides a snapshot of the patient’s hospital
course, including a healthcare needs list and treatments provided, as well as a
plan for future follow-up and a list of discharge medications. This is combined
with discharge paper- work from the nursing and pharmacy staff that includes
educational information pro- vided to the patient, such as medication leaflets and
postdischarge instructions (e.g., wound care directions, date of follow-up
appointment with primary care physician).
Outpatient medical records typically include notes from all office visits.
Addition- ally, any clinical notes from hospitalizations are often copied and
placed in the paper chart or are scanned and placed in the electronic medical
record to permit continuity of care.

treatment notes
Treatment notes are utilized most frequently in the inpatient setting. Treatment
notes include medication orders, medication administration records (MARs),
documenta- tion of surgical procedures, and documentation of services such as
radiation therapy, physical therapy, occupational therapy, respiratory therapy, and
nutrition. All of these areas of the chart are important to review, because each
provides details regarding the execution of the patient’s treatment plan.
Medication orders can be transcribed by the practitioner onto a paper order
form; these can then be faxed, scanned, or copied and sent to the pharmacy for
processing and filling. Alternatively, the practitioner may enter the medication
orders directly into the computer system using computerized prescriber order
entry (CPOE, discussed below); the orders are then reviewed and
46 chapter 2 / the medical record

processed by the pharmacist. The orders section of the chart may also contain
orders from other practitioners, including physical and occupational therapists,
respiratory therapists, and nutritionists. Rationale for these orders can be found
in the treatment notes section for each of these practitioners. This provides
insight as to the patient’s entire problem list, because these practitioners play
important roles in managing vari- ous healthcare needs on the individual patient’s
list.
Medication administration by nurses and other practitioners (e.g., respiratory
therapists, physical therapists) is documented via MARs. These can be paper-
based or electronic (eMAR) and permit one to view the dates and times of all
medications administered to the patient as well as documentation of missing or
refused doses.

electronic and paper-based data collection systems

Records of patient information, including the official medical record, can exist in
either electronic or paper-based formats, or a combination of both. Regardless of
the format an institution is using, the types of patient data and documentation
available typically include the components that have been described previously
in this chap- ter. As technology continues to advance in the healthcare arena, the
capabilities of electronic medical record formats continue to expand, including
providing improved accessibility of patient data via handheld mobile devices.
Electronic medical record systems vary by vendor and institution and can include
the components described previously. As with paper-based formats, the Health
Insurance Portability and Accountability Act (HIPAA) Security Rule
encompasses protected health information stored in electronic formats; this
requires health- care organizations to ensure the confidentiality and security of
this information.3 CPOE technology allows the provider to enter an order for a
patient; the order can then be viewed and confirmed in the same or a related
electronic system. For example, a physician could input a medication order for a
specific patient into an electronic system and then the order could be
communicated electronically to the pharmacist. Figure 2.1 shows an example of a
computer screenshot from current CPOE technology. With this system, each of
the patient’s providers can view the patient’s current medications, as well as any
discontinued medications. This process may help to reduce or eliminate errors
that are associated with paper-based systems, including errors attributable to
poor provider handwriting.4 Additionally, decision- support tools embedded
within the electronic system may offer additional assis- tance to providers. Often,
the computerized system that houses the CPOE includes additional files within a
patient’s medical record to support electronic filing of dic- tated patient care
notes, radiologic and laboratory data, and more. An example of
 components of a patient’s medical record 47

figure 2.1 Example of a computerized prescriber order entry (CPOE) system.

electronic laboratory result data is shown in Figure 2.2. It is important to note

that although an institution may utilize an electronic system, not all of the data
available in that institution may be recorded electronically; data that are only
recorded in paper format despite the presence of an electronic system should be
identified.
In addition to maintaining the patient’s permanent record, inpatient systems
may record medications as they are administered to the patient, thereby
maintaining an interactive patient eMAR. Figure 2.3 presents a screenshot of a
sample eMAR. In the outpatient setting, similar technologies can facilitate
sharing of patient and electronic transfers of medication prescription requests.
For example, prescription requests, along with supportive data, may be
transferred electronically to a pharmacy. Limita- tions to implementation of such
software in healthcare institutions tend to include cost, workflow support,
training, and organizational factors.5 Paper-based records should offer the same
data recorded as the electronic medical record.
Patients are permitted to receive copies of their medical records, but the
proce- dures for this must be set forth by the healthcare institution in accordance
with state
48 chapter 2 / the medical record

figure 2.2 Example of laboratory data stored in an electronic system.

and federal law. Typically, patients can review their medical record in the medical
records department of the institution or receive results of laboratory and
diagnostic testing from their physician.3
Pharmacists can follow a number of steps to prevent improper disclosure of
medi- cal information, thereby preventing legal consequences and fines:
• Providers should keep clipboards and folders containing patient
information with them at all times and/or in a secure area (e.g., in a locked
file in the phar- macy department).
• Providers should follow the institution’s policies for retaining and
discarding health information. This may involve storage of information in
locked cabinets and shredding materials when they are no longer needed.
• Providers should sign off of the computer system when they are finished
using it. Applications with patient information should never be left open,
even if the provider just gets up for a minute to answer a phone or to use
the restroom.
 systematic approach to data collection 49

figure 2.3 Example of an electronic medication administration record (eMAR).

systematic apprOach tO data cOLLectiOn

Considering the often large amount of data available in the patient’s medical
record, pharmacists must use a systematic approach to review patient data. This
process involves reviewing pertinent and timely components of the patient’s
medical record, the MAR, and other relevant data, and then compiling this data.
Data may be tran- scribed onto a written or electronic data collection form and
can be used by the phar- macist to maintain an accurate, consistent, and
organized view of the patient for the purposes of developing a focused
pharmacy-related assessment and plan of care.
Data are often streamlined to make it easier to provide pharmaceutical care
to the patient; however, the data must be comprehensive enough to ensure that
the phar- macist maintains a complete understanding of the patient. Data may be
focused on a single visit in the outpatient or urgent care setting or on a single day
or visit during an inpatient hospital stay and then updated daily. A systematic data
collection process can help the pharmacist stay organized from patient to patient,
day to day.
50 chapter 2 / the medical record

Data collection methods may vary between pharmacists or clinical sites; however,
they share the common goal of allowing a consistent review of a single patient or
multiple patients at once. This approach usually involves the use of a paper-
based or electronic form that has enough space to include all of the relevant
material that the pharmacist may need to collect. These forms are often
developed or tailored to meet the needs of a specific pharmacist with a
designated set of patient care responsibilities and may be formatted to mirror the
order in which the pharmacist will either collect or interpret the data.
The benefits of a systematic approach are numerous. First, it allows the phar-
macist to routinely organize information pertinent to the pharmaceutical care of
the patient in a consistent manner. Second, systematic data collection allows the
phar- macist to maintain a process during which potential drug-related problems
may be evaluated. Third, this approach allows for ease of patient care “pass-off”
should the pharmacist transfer care of a patient to another pharmacist.
Additionally, the phar- macist’s collected data may become a resource for
reporting on patient care during rounds, facilitating discussion with other
healthcare practitioners, or documenting clinical interventions.

initiating the systematic approach to data collection

A primary goal of systematically collecting data from the patient record should
be to keep the process simple yet relevant and comprehensive enough for a
pharmacist’s needs. A key in this process is not to overcollect data because it is
available, but to be sure that there is a use and a reason for each type of data
being collected. Because this may become a routine activity as a part of patient
care, efficiency and consistency in collection of data become important. For
example, a pharmacist may have many patients under his or her immediate care
and may need to review data on each of these patients.
Timing of patient data collection usually follows a three-point approach: a
preencounter assessment, a mid-encounter assessment, and a postencounter
assess- ment. Regardless of the setting, the role of the pharmacist in the
preencounter assessment is often to gather data relevant to the care of the patient
for a given task (e.g., clinic visit, patient care rounds), and this is typically
conducted prior to meeting with the patient or provider team. Data can then be
updated or augmented during the mid-assessment encounter with the patient
based on additional findings or the patient interview. Finally, monitoring and
follow-up of new or changed data should occur, and the data collection form
updated accordingly in the postencoun- ter assessment.
 systematic approach to data collection 51

types of systematic data collection forms

As discussed previously, data collection forms are often individualized to a given
phar- macist or role in a clinical setting. An example of a data collection form is
shown in Figure 2.4; however, this form serves only as a starting point to
demonstrate that forms may be customized and include space for data.
Individual forms will be tai- lored to meet the needs of the practitioner and will
vary based on the practitioner or situation. Data on the form that is not within
the scope of practice for the phar- macist to obtain may be collected from the
medical record, as described previously.

Age: Weight: Height: Allergies:

Chief complaint:

History of present illness:

Past medical history:

Family history: Social history:

Home medication and Route: Frequency: Last dose (date/time):

dose:

Physical exam:

ROS:

Laboratory data and serum concentrations:

Current medication Route: Frequency: Indication:

and dose:

Problem list: Patient plan:

figure 2.4 Sample pharmacist data collection form.

52 chapter 2 / the medical record

Data collection forms are heavily influenced by the manner in which the pharmacist
is likely to assess the patient; therefore, the format and data vary based on the type of
prac- tice setting or provider service. Several factors may play a guiding role in the
decision to use a particular type of data collection form, including the clinical setting
(e.g., inpatient or outpatient), the role of the patient care team (e.g., primary team
or consult service), or the specific task presented to the pharmacist (e.g., assessment
of a focused problem or a generalized workup of the patient). Regardless of the
nuances among data collection forms, applying a systematic method of data
collection from a patient’s medical record is key to ensuring consistency in the
approach, assessment, and plan for each patient.

pharmacy-reLated cOmpOnents
Of the patient medicaL recOrd
A critical skill for the efficient pharmacist is to review the data with several key
pharmacy-related aspects in mind; this will permit concise data collection while
providing the pharmacist with adequate information to develop recommendations
to optimize pharmacotherapy. Depending upon the patient care responsibilities of
the individual pharmacist, the pertinent pharmacy-related components of a
patient’s chart may vary. For example, an infectious diseases clinical pharmacist
may dive right into the chart to seek out antibiotic orders and laboratory data for
serum drug concentrations and renal function assessments, whereas a cardiology
pharmacy specialist may initially search for blood pressure values from the physical
examination in order to assess the effectiveness of a patient’s antihypertensive drug
regimen. Regardless of specialty or focus, several general pharmacy-related
components are contained within each portion of the medical record.

medical history
The medical history (H&P) is a key area for identifying drug-related problems,
which will be discussed at length in the final section of this chapter. Thus, the
majority of information contained within the H&P is valuable in developing an
assessment and plan for interventions to optimize pharmacotherapy. The
pharmacist may find data lacking in some areas, which will require clarification via
additional patient interview- ing. For example, a patient’s chart may indicate an
allergy to penicillin, but the specific reaction not be identified. The pharmacist
can then question the patient to obtain and document this important piece of
information. Similarly, components of the medica- tion history may not be
complete. For example, the H&P may note a medication list without doses or
frequency of administration. The pharmacist can question the patient
 pharmacy-related components of the patient medical record 53

and even contact the patient’s pharmacy to obtain this information for
documentation in the chart and on the pharmacist’s data collection form.
Additionally, physical findings may be germane to assessing the patient’s
response to medications that are either missing or not documented in the chart.
These require the pharmacist to perform the appropriate assessment technique to
obtain and docu- ment the finding. For example, the physical examination of a
patient who presents to the hospital with nausea and vomiting resulting from
phenytoin toxicity should note the presence or absence of nystagmus, a finding
associated with supratherapeu- tic serum concentrations of the drug. If this
information is not found in the medical record, the pharmacist should perform
the appropriate assessment (in this case, the H test to assess for nystagmus) and
document the finding accordingly.
Throughout the H&P, the pharmacist can identify pertinent positive and
nega- tive components that are key to the development of an assessment and
plan. This becomes especially important when gathering data from the HPI, ROS,
and PE. The importance of pertinent positives can be easily rationalized, while
pertinent negatives are not so obvious. For example, if the family history of a 39-
year-old man presenting to the emergency department with a myocardial infarction
indicates no family history of coronary artery disease, it is a pertinent negative fact
to note on the data collec- tion form, because it might be expected that someone
in the patient’s family would have preexisting cardiac disease. Another example
would be a patient presenting with pneumonia who has no shortness of breath
(SOB). The pharmacist should document “no SOB” in the ROS of this patient,
because it is a pertinent finding for this patient. A large majority of the H&P is
relevant to the pharmacist’s data collection.

Laboratory and diagnostic test results

In the lab section, pharmacists can focus on a number of pharmacy-related data
points, including labs reflecting effects of disease states and medications on
organ systems (e.g., serum creatinine, liver function tests, CBC, urinalysis), serum
drug concentra- tions (e.g., vancomycin, phenytoin, digoxin), and cultures. Again,
pertinent negative values are important to document, because some patients may
have some unexpectedly normal labs (e.g., normal liver function tests in a patient
with a history of liver disease). Diagnostic test results become important for the
pharmacist to gather in order to understand the status of the patient’s various
healthcare needs. Again, normal results of diagnostic tests can be just as valuable
as abnormal results (e.g., normal electrocar- diogram in a patient with chest pain)
and thus should be recorded by the pharmacist on the data collection form.
54 chapter 2 / the medical record

clinical and treatment notes

As discussed previously, these areas contain a large amount of information.
Many pieces of data here can be considered key pharmacy-related components,
including:
• Updates to problem lists, including new or changed diagnoses
• Daily updates regarding the patient’s ROS and PE, including daily vital
signs, ins and outs, etc.
• Nursing notes, including updated vital signs, ins and outs, pain scores, reasons
for refused or delayed medication administration, intravenous line site
status, daily body weights, etc.
• Input from specialists regarding the status of various problems on the patient’s list
• Prescriber rationale for changing a medication regimen, dosage, and/or
duration
• MAR/eMAR, including confirmation that scheduled medications were admin-
istered, timing of medications (e.g., vancomycin, and aminoglycosides), timing
of as needed medication administration (e.g., analgesics, antipyretics,
sliding scale insulin), or fingerstick blood glucose results

navigating chOppy Waters: What tO dO if infOrmatiOn is

missing and/Or mispLaced

One of the greatest challenges in gathering information from a patient’s chart is

actu- ally locating all of the required data. It is critical to collect all pertinent
information from the medical record in order to create a thorough and complete
assessment, prob- lem list, and plan for an individual patient. It can be
frustrating to search the chart for a piece of information and not find it where it
should likely be. Several issues can arise when navigating the choppy waters of
the medical record.

missing details
Details are often missed during the documentation of the PMH. For example,
a patient who is HIV positive should have the year of diagnosis and the most
recent viral load and CD4 T-cell counts listed. The chart of a patient with
diabetes, for example, should have the type of diabetes documented (i.e., type 1
or type 2) as well as any associated complications (e.g., diabetic retinopathy,
neuropathy, nephropathy). If these clarifying details are missing, they can often be
located in other areas of the chart, including H&Ps from previous admissions or
visits, previous lab studies, and even from interviewing the patient.
 navigating choppy Waters: What to do if information is missing and/or misplaced 55

information in the Wrong Location on the chart

Information may be located in the wrong section of the chart. This most
commonly seems to occur with the review of systems and the physical exam. It is
important to remember that the ROS is not the PE; inexperienced practitioners
may inadvertently document a physical finding in the ROS section, or vice versa.
For example, shortness of breath may be documented in the pulmonary part of
the PE, when it should be located in the respiratory system part of the ROS,
because it is a symptom subjectively perceived and reported by the patient. This
occasionally occurs with FH and SH; inexperienced providers may place
information regarding marital status in the FH section, for example. When
navigating a patient’s chart, the reader must be aware of the potential for
misclassification of data and ensure that the data are properly placed on the data
collection sheet.

conflicting information
Conflicting information may become an issue when multiple practitioners
perform H&Ps on the same patient. For example, the PE performed by the
medical stu- dent may note that the patient’s breath sounds are clear to
auscultation bilaterally, whereas the resident physician has documented rales
and rhonchi in the left lower lobe of the lung. Clarification of conflicting
information may require reviewing fur- ther information in the chart in addition
to speaking with the team of practitioners taking care of the patient.
Additionally, the pharmacist may interview the patient and perform a physical
assessment of the patient to determine a resolution for the conflicting
information.

Locating all of the information

Occasionally, it may be difficult to obtain a patient’s inpatient paper chart
because it is being used by another practitioner or because it is sent with the
patient when he or she leaves the medical floor for diagnostic testing (e.g., x-ray)
or procedures (e.g., surgery). When this occurs, information gathering can begin
with using the electronic medical record system to gather laboratory and dictated
information. Any informa- tion that cannot be obtained in this manner can then
be followed up on when the paper chart becomes available. Additionally, there may
be a high demand for computer terminals on nursing floors or in a cramped
ambulatory care clinic setting. Again, patience is key; it may be best to start with
a review of the paper medical chart first and then review the electronic medical
information once a computer becomes available. Alternatively, finding a separate,
secure location with additional terminals, including
56 chapter 2 / the medical record

a different medical floor or a medical library, will permit review of electronic

informa- tion in a timely manner. It may also be helpful to perform reviews of
medical records at “off hours” on the patient care floor, such as very early or late
times of the day or during resident physicians’ mandatory conferences, because the
demand for charts and computers is often lower at these times. Once gathered on
a data collection sheet, the pharmacist can synthesize all of the key pieces of
information in the medical chart to develop a comprehensive healthcare needs
list.

synthesizing patient infOrmatiOn:

deveLOping a prObLem List
Once a patient’s information is gathered from all of the necessary sources, the
pharma- cist can create a comprehensive list of pharmacy-related healthcare
needs that encom- passes a patient’s disease states, drug-related problems, and/or
preventive measures. This problem list should be prioritized, with the most clinically
significant issues listed first. For example, a male smoker presenting to the
emergency department complain- ing of shortness of breath who is diagnosed
with community-acquired pneumonia (CAP) should have pharmacy-related
problems associated with “CAP” listed as the number one healthcare need on his
list, while smoking cessation will be lower in pri- ority on the list. Creation of this
list can be challenging; however, with an organized systematic approach, it can
be done efficiently and effectively.

disease states
Often referred to as medical problems, the disease states a patient has should be
included in the healthcare needs list. These are often derived from acute
diagnoses, as in the case of a patient in the hospital setting, and from the PMH.
Practitioners such as phy- sicians, physician assistants, and nurse practitioners
are the primary caregivers who diagnose and document these disease states in the
medical record. Examples of disease states include hypertension, hyperlipidemia,
otitis media, and CAP.

drug-related problems
Drug-related problems (Drps) are events or issues surrounding drug therapy
that actually or may potentially interfere with a patient’s ability to receive an
opti- mal therapeutic outcome.6 DRPs are separate entities from a patient’s
specific disease state. In practice, the pharmacist can help determine the presence
of actual or poten- tial DRPs. Any observed DRPs should be added to the
patient’s healthcare needs list and ultimately serve as the foundation for the
pharmacist’s assessment of the patient.
 synthesizing patient information: developing a problem List 57

Each DRP can be considered as an overall problem, but may be expanded as

specific problems are considered. Several DRPs have been described:6–10
• Indication lacking a drug. Each diagnosis or indication should be
reviewed to determine the presence or absence of appropriate drug
therapy, including synergistic or prophylactic drug therapy. Indications
that need drug therapy, yet are lacking in any or complete therapy, should
be evaluated further. An example of this DRP includes a patient with a
history of coronary artery disease and hyperlipidemia who does not have
any medications prescribed for hyper- lipidemia. This DRP may also be
observed in a patient with generalized anxi- ety disorder who has not
received an antianxiety medication (e.g., a selective serotonin-reuptake
inhibitor, benzodiazepine, etc.).
• Indication with incorrect drug. Each diagnosis or indication should be
reviewed to determine if the therapy associated with it is effective or
correct, not only with the drug itself, but also with the route of
administration. Often, this DRP warrants reevaluation as a disease
progresses, patient tolerance increases, or efficacy is not observed. An
example of this type of DRP would be a patient treated with intravenous
vancomycin for Clostridium difficile colitis. The route of administration for
vancomycin for this indication should be oral, because the intravenous route
is ineffective.
• Wrong dosage. This DRP incorporates a drug dose that may be too high
or too low. Both instances can alter the efficacy and safety of a therapeutic
agent and requires evaluation. Additionally, dose frequency and duration
should be evaluated. For example, a patient who is HIV positive and who
receives atazanavir 200 mg daily as a component of her antiretroviral
drug regimen would have this DRP on her problem list, because this dose
of atazanavir is too low.
• Inappropriately receiving drug. This DRP may alternately be described
as the patient having problems with compliance or adherence to a
particular medication or regimen. However, this DRP may also pertain to
patient misun- derstanding about how a specific drug should be taken or
lack of availability of the agent, perhaps due to manufacturing availability
issues or patient financial issues. An example of this DRP would be a
patient who misses 2 weeks of his treatment regimen for hepatitis C
infection due to not receiving it in the mail from his mail order pharmacy.
• adverse reaction to a drug. Adverse drug reactions (ADRs) should be
assessed. If an offending agent is found, it may be discontinued. For
example, if a patient receiving ampicillin on the inpatient floor breaks out
into a rash
58 chapter 2 / the medical record

following treatment initiation, she may be experiencing an ADR and

should be appropriately evaluated.
• Drug interaction. Drug therapy should be evaluated as a whole for each
patient, and the presence of potential or actual interactions with drug
therapy should be considered and evaluated. This is especially important to
assess when a patient is on medications with a high propensity for drug
interactions, as in the case of a patient receiving rifampin for treatment of
tuberculosis.
• Drug lacking indication. All drugs should be directly connected to a
particular indication. If an indication is not present or is no longer present
for a specific drug, the patient may need to be weaned off the agent or
discontinue it. For example, a patient receiving hydrochlorothiazide who
does not have hyperten- sion on his problem list and who denies having high
blood pressure should have this DRP documented on his problem list.

DRPs can vary in nature and often arise from the disease states present on
the patient’s problem list. It is easy to become overwhelmed when trying to
identify all of the DRPs for an individual patient. Thus, following an organized,
stepwise process is key to ensuring that all DRPs are identified and prioritized
properly.9 This organized approach is summarized in table 2.4. Step 4 in Table
2.4 permits the pharmacist to quickly recognize if a DRP exists with a particular
medication. If the answer to any of the first four questions is “no” or if the
answer to the last question is “yes,” further investigation to identify DRPs is
necessary. Once all DRPs are identified, they can be prioritized and merged into
the problem list with the patient’s disease states.10
For example, consider the following patient encounter. An otherwise healthy
patient arrives at the clinic after completing a trial of lifestyle changes for his
recent diagnosis of hypertension. At this current visit, the patient’s blood
pressure remains elevated, and, along with the prescribing practitioner, the
pharmacist agrees to help develop a medication plan for this patient. The
pharmacist reviews all necessary data, including the patient’s medical history,
allergies, and contraindications, cur- rent hypertension guidelines, and
appropriate drug information, and suggests to the prescriber that she initiate an
antihypertensive medication at an appropriate starting dose and frequency. The
pharmacist documents the patient’s DRP as “indication lack- ing drug.” Note
that this is different from the physician-diagnosed medical problem, which would
be “hypertension.” At follow-up visits with this patient, the pharmacist will likely
assess the patient for additional potential DRPs, including potential nonad- herence,
drug interactions, and the presence of adverse drug reactions. If any of these
were observed at the follow-up visit, the pharmacist could work with the
prescribing practitioner to prioritize existing DRPs and create a plan for each
problem.
 synthesizing patient information: developing a problem List 59

tabLe 2.4 steps to recognizing drps

1. Know what the DRPs are. It may be helpful to keep a list in front of you until you feel more
comfortable with them.

2. Gather patient data from the H&P and notes. Use an organized data collection sheet for
recording all information required, including a draft of the patient’s problem list.

3. Isolate each problem on the problem list and identify the medications being administered for
each problem. Creating a table like that shown below may be helpful:

problem List (in descending order medications patient is receiving for each problem
of priority) (drug, dose, route of administration, frequency)

A drug information resource may assist with this step.

4. Screen each medication on the patient’s list with the following questions:

• Is it the right drug for the indication?

• Is it the right dose?

• Is the drug working?

• Is the patient taking the drug appropriately?

• Is the drug causing ADRs or drug interactions?

If the answer to any of the first four questions is “no,” or if the answer to the last question is
“yes,” further investigation to identify DRPs is necessary.

5. Once all the DRPs are identified, they can be integrated into the overall problem list prioritized
in order of most clinically significant to least clinically significant.
Source: Kane MP, Briceland LL, Hamilton RA. Solving drug-related problems. US Pharm. 1995;20:55–74.

preventive measures
Healthcare professionals additionally take action to prevent illness. This often
takes the form of health maintenance actions, such as administration of routine
immuniza- tions (e.g., influenza, pneumococcal), and patient education, such as
smoking cessation counseling. Also included in this category are prophylactic
measures against acute ill- ness, including deep vein thrombosis prophylaxis and
stress ulcer prophylaxis, each of
60 chapter 2 / the medical record

which may be necessary in at-risk hospitalized patients. Oftentimes, these preventive

measures are lower in priority than most of the disease states and DRPs on a
patient’s problem list; however, it is important that they are included.

case study
Consider the following case study and the pharmacist’s development of an
appropriate problem list.

CC: “I am so dizzy and confused!”

HPI: ZZ, a 40-year-old man, is brought to the emergency department by his wife on a December
morning. ZZ complains of increasing dizziness, lethargy, and confusion over the past 3 days. He
also describes diplopia for the past day. ZZ’s wife notes that ZZ can barely walk in a straight line.
PMH: Seizure d/o x 15 years, HTN

FH: NC

SH: Does not smoke, no ETOH use, lives at home with wife, works in construction operating a
bulldozer
ALL: PCN (hives)

Meds PTA: Phenytoin 300 mg PO 3 times daily; HCTZ 25 mg PO daily; ibuprofen 800 mg
PO 6 times daily as needed for headaches
ROS: + for dizziness, confusion, lethargy, diplopia, nausea; – for vomiting, diarrhea

PE:

VS: 110/70, 98.5, 99, 14, 67 inches tall, 60 kg

HEENT: PERRLA, + nystagmus,

MMM Neck: Supple, no JVD, no

LAD Lungs: CTA bilaterally
Heart: S1S2, no m/r/g

Abd: NTND, + BS

Neuro: + Romberg, A&O x 1, CN assessment not performed due to patient’s inability to

follow directions
Rectal: Deferred

LAB: Na 138; K 3.7; Cl 100; CO2 25; BUN 10; SCr 1.1; Glu 94; AST 19; ALT 20; Tbili 1.0;
albumin 4.0; phenytoin 35 mg/L; CBC: pending
 chapter summary 61

tabLe 2.5 problem List

priority problem List type of problem

1 Adverse drug reaction to phenytoin secondary to Drug-related problem

supratherapeutic serum concentration (adverse drug reaction/wrong
dosage)

2 Seizure disorder Disease state

3 Overdosage of ibuprofen for headache Drug-related problem (wrong

dosage)

4 Hypertension Disease state

5 Influenza immunization Preventative measure

Based on the pertinent information from the H&P and reviewing the
information closely for DRPs using the method described in Table 2.4, the
pharmacist caring for ZZ has developed a problem list documented in order of
priority from most clinically significant to less clinically significant (table 2.5).

chapter summary
Although it is easy to become overwhelmed by the voluminous amount of
informa- tion available in the patient’s medical record, it is important to gain
perspective on the components of the medical record, whether it is available
electronically, on paper, or both. It is important to develop a strategy for
collecting data and identifying the pieces of information that are critical to the
creation of a problem list. Additionally, the step- wise approach to developing a
problem list that includes the drug-related problems presented in this chapter
will allow you to efficiently prioritize the issues that impact your patient. This
can then be taken to the next level through provision of pharma- cotherapeutic
recommendations to the prescriber in order to optimize drug therapy and
outcomes.

Take-Home Messages
• It is critical to develop a systematic approach to gathering and
documenting patient information from written and electronic medical
records. Becoming comfortable with a consistent data review format will
assist in efficient data gathering.
62 chapter 2 / the medical record

• As you become more and more familiar with the key pharmacy-related
compo- nents of the medical history and physical examination, you will
find it easier to navigate the chart to obtain the information you need.
• Be sure to follow an organized method for identifying each of your
patient’s problems. Utilizing the steps to recognize drug-related problems
will allow you to easily identify issues that should be noted on your
patient’s prob- lem list, in addition to their medical problems and potential
preventative measures.

revieW QuestiOns
1. What are some challenges that arise when searching for information in the
medical record?
2. What is the difference between clinical notes and treatment notes?
3. What are some ways that information can be systematically collected from
a patient’s medical record for the purposes of developing an assessment
and plan?
4. What are key pieces of information that should be gathered from the H&P
in order to identify drug-related problems?
5. What are some ways in which drug-related problems are utilized to create a
pharmacist-driven problem list?

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