A pharmacist may review a patient's overall medication requirements to ensure the effective use of medicine, following a diagnosis(es) made by another health care professional, in order to maximise therapeutic outcomes. A review of the patient's overall medication requirements involves analysing the patient's medication record to assess the appropriateness and cost-effectiveness of treatment to ensure rational drug use, and to identify possible interactions and adverse drug reactions. It also involves developing a plan of action in collaboration with other health care professionals and the patient as well as the necessary follow-up. Such a review may involve a consultation with the patient. Full records must be kept.

The responsibility of the pharmacist who provides such a review is to care for a patient's medicine-related needs by making sure that all of a patient's medicine therapy is appropriate, the most effective available, the safest possible and is used as indicated. This is accomplished by identifying, resolving and preventing medicine therapy problems that could interfere with meeting a patient's medicine therapy goals successfully and producing positive patient outcomes.

It is not necessary to provide an overall review of all patients' medication requirements every time they visit a pharmacy. Situations that would justify such a review are any of the following:

A patient can request a review of his/her medication by asking the pharmacist for help with regard to a medicine-related problem. Another health care provider, for example a medical practitioner, nurse, dentist or another pharmacist, might refer a patient for a medication review or a pharmacist's assistant or another pharmacist dispensing medicine to a patient might identify some need for care.

The review process must be systematic, structured, ongoing and documented. It consists of three important steps:

Where a pharmacist performs an overall review of the patient's medication, the following standards are applicable:

Regardless of the practice environment, a common set of information should be collected for each patient. The following information should be included in a comprehensive pharmaceutical care database:

During the assessment phase the pharmacist should evaluate the patient's medicine therapy including any new prescription of a patient with the aid of all the information gathered in order to ascertain any of the following:

Where a new prescription must be dispensed this must be done in accordance with the standards laid down in section 2.7 of this manual.

The pharmacist must upon recognising any problem/situation as described above, take the appropriate steps which could include the development of a care plan to avoid or resolve the problem(s). Care plans are developed to define goals, determine appropriate interventions and to assess whether the patient's needs have been met. It also defines responsibilities of the patient and pharmacist for three different purposes:

The pharmacist must consult with the prescriber and/or the patient's medical practitioner when it is deemed necessary by the pharmacist to resolve a medicine-related problem. During this step it is also the responsibility of the pharmacist to provide adequate advice to the patient to ensure the safe and efficacious use of medicines. The patient should receive an unequivocal understanding of the instructions for use, and any distinct characteristics or requirements of the medicine. Counselling should cover matters that will enhance or optimise medicine therapy. Counselling of patients or their caregivers should thus include at least the following information—

When the patient or the patient's caregiver is present, the pharmacist should consult with the patient/caregiver in person. Such a consultation should take place in an environment that allows for confidential conversation (refer section 1.2.13).

The care plan is completed when goals have been set, interventions agreed upon, and responsibilities of the patient and pharmacist are accepted. The pharmacist is then able to establish outcomes to be assessed during follow-up. The last step of the care-planning process is to schedule a time to conduct a follow-up evaluation.

The final step in the review process is the follow-up evaluation of the patient to determine actual patient outcomes. A follow-up evaluation is a patient encounter, either in person or by telephone, which allows the pharmacist to collect necessary information to determine whether the actions and interventions taken during the assessment and care planning have produced positive results. Since medicine therapy could produce both positive and negative results, a follow-up evaluation is vital. In addition, routine discussions with the patient's medical practitioner or other health care professionals might also be necessary.

These three steps provide the pharmacist with an organised logical mechanism to structure the provision and evaluation of care to patients. The above three steps occur continuously for a patient during treatment. The amount and type of work required at each step varies with the particular step and the specific needs of a patient. Other health care providers must be included in the patient care process when their input is needed to meet the patient's medicine-related needs. A pharmacist providing this service to patients is required to maintain the data base as per the standard and in addition to create and maintain reports reflecting each of the three steps of the pharmaceutical care service rendered.