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Basic FHIR Pharmacist electronic Care Plan

Click here to download the sample file.

This example file documents a Pharmacist Care Plan done by Cody Pharmacist, RPh of Durham Independent Pharmacy for Test Middle Patient Jr. of Durham.

Mrs. Patient, a dually-eligible Medicare/Medicaid patient presents for an in-person initial visit. Cody Pharmacist interviews Mrs. Patient and asks her about her allergies, medications and any problems she might be having with her medications.  Cody Pharmacist also pulls up and reviews Mrs. Patient’s recent prescription fill history from the pharmacy inventory system.  Mrs. Patient reports that she is not allergic to anything.

Medication History:

Mrs. Patient takes metformin 500 mg BID, prescription written 12-13-2016 by Primary Doc, MD.  She filled it for a 30 day supply on 11-1-2017, 10-1-2017 and 9-1-2017.

On file, Mrs. Patient has a prescription for enalapril 10 mg qday, written 12-13-2016 by Primary Doc, MD.  The enalapril was last dispensed on 11-1-2017 for a 30 day supply, with additional 30 day fills on 10-1-2017 and 9-1-2017.

Mrs. Patient also has an inactive prescription for lisinopril 5 mg qday on file, written 4-5-2017 by Primary Doc, MD.  The lisinopril was last dispensed on 8-17-2017 for a 90 day supply.  Mrs. Patient reports that she takes this medication “when she feels that she needs it.”

Mrs. Patient also has a prescription on file for zolpidem 10 mg qhs prn sleep, written 2-11-2017 by Primary Doc, MD.  Mrs. Patient reports that she has taken this medication every night since it was prescribed.  It was last dispensed on 11-1-2017 for a 30 day supply, with additional 30 day fills on 10-1-2017 and 9-1-2017.

Based on his interview and this medication history information, Cody identifies two drug therapy problems associated with Mrs. Patient’s current regimen. Mrs. Patient should have discontinued her lisinopril when the enalapril was initiated, as this represents a therapeutic duplication (SNOMED Code: 435481000124101 – Multiple medications taken for condition appropriately treated with single medication therapy (finding)). Additionally, Mrs. Patient is overusing her zolpidem (SNOMED Code: 6071000124102 – Medication overuse (finding)), which is intended only for the short-term treatment of insomnia.

To address these problems, Cody Pharmacist educates Mrs. Patient about the need to discontinue her lisinopril (SNOMED Code: 4701000124104 – Recommendation to discontinue medication (procedure)).  Together, Cody and Mrs. Patient identify a goal for her to take all of her medications as prescribed.  Additionally, Cody recommends that Mrs. Patient see her primary care doctor (SNOMED Code: 183561008 – Referral to general practitioner) to discuss her long-term options for treating her insomnia.  Mrs. Patient sets a goal to improve her sleep hygiene to reduce the need for medications.  Cody sends a message to Primary Doc to inform him of the issue of Mrs. Patient’s overuse of her zolpidem.

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