A care plan records the health or medication-related problem a patient wants to address, the agreed goal, what each person will do and how progress will be checked. A useful care plan template keeps those decisions together so the next pharmacist can continue the work without reconstructing it from several visit notes.
Use this template when building or refining your pharmacy's own care-plan documentation. For a health-plan-assigned comprehensive medication review (CMR), start with the program's workflow and designated platform: it may already provide the fields, templates and patient materials you need.
A care plan template for a pharmacy medication review
Keep the patient's identifier, encounter date and documenting clinician with the plan in the clinical record. Repeat the problem section for each priority that needs its own goal or follow-up.
Patient priority and assessed problem: [What matters to the patient? What medication-related need did the pharmacist identify, and what relevant information supports it?]
Agreed goal: [What should change, and how will the patient and pharmacist recognize progress?]
Actions and owners: [What will the patient, pharmacist or another person do? Distinguish an agreed action from a recommendation awaiting a decision.]
Follow-up: [Who will check which result, when or after what event, and how will they reach the patient?]
Review update: [What happened, what remains unresolved and what changes in the plan? Include the review date.]
The JCPP Pharmacists' Patient Care Process supports planning with the patient, addressing medication-related needs, agreeing on goals and evaluating progress. Clinical targets, monitoring and timing still come from the individual assessment and applicable service requirements.
Use a goal the patient can understand. “Improve adherence” leaves the next conversation vague. “Have an affordable way to obtain the next supply before the current supply runs out” identifies a result the patient and pharmacist can check. A clinical goal may also need a specific measurement and target; don't insert a standard target just because the template has an empty field.
Filled example: the next refill costs too much
This hypothetical example concerns a patient who is taking a medication but says they cannot afford the next refill. It illustrates documentation, not a recommendation to change a particular treatment.
Patient priority and assessed problem: The patient wants to continue treatment but reports that the next refill is unaffordable. At the October 19 review, the pharmacist confirms the medication and enough remaining supply through October 24. The next supply's cost is unresolved.
Agreed goal: Before October 24, the patient and pharmacist will establish an affordable, clinically appropriate way to continue treatment, or escalate the unresolved access problem for a timely clinical decision.
Actions and owners: The pharmacist will check the patient's current coverage and available cost options. If a different treatment is a possible option, the pharmacist will send the relevant information and recommendation to the prescribing clinician for a decision. The patient agrees to discuss the available options with the pharmacist and report if the supply will run out sooner than expected.
Follow-up: The pharmacist and patient agree to speak on October 21, leaving time to act before the supply runs out. At that contact, the pharmacist will check whether an option was approved, whether the patient accepts its cost and whether the next supply can actually be obtained. A still-pending clinical decision remains assigned for follow-up.
Review update: October 21: a lower-cost option has been identified, but a required treatment-change decision is still pending. The pharmacist follows up with the prescribing team that day and agrees to update the patient on October 22. The access problem remains open.
“Recommendation sent” describes completed communication. It doesn't establish that the patient has an affordable next supply. If the patient later obtains the agreed treatment, the review can document that result and move to any remaining monitoring. If the option is still unaffordable, the plan needs a different action rather than a completed label.
Care plan, SOAP note, patient action plan or eCare Plan?
These documents can describe the same care while serving different readers and systems.
A SOAP note organizes an encounter into subjective information, objective information, assessment and plan. Its plan section can contain the current care decisions. When a problem spans several encounters, keep the current goal and outstanding actions easy to find instead of leaving them only in an old note. Our clinical documentation guide covers the broader note formats.
A patient action plan gives the patient their agreed next steps in language they can use. In the affordability example, it would name the planned contact and ask the patient to tell the pharmacy if their supply situation changes. It shouldn't leave the patient responsible for an insurance investigation or clinician response that the pharmacist agreed to handle.
A Medicare Part D comprehensive medication review is part of the health plan's MTM program. CMS requires a standardized written summary for the patient, but participating pharmacies must also follow the plan or administrator's documentation and claim-submission requirements. A paper care plan alone doesn't establish that those payment requirements have been met.
For example, the Outcomes CMR workflow recommends a printed worksheet for taking notes during the review, then directs staff to update the platform's patient records and action plan, deliver the Patient Takeaway and submit the claim. Use the supplied workflow for an assigned CMR. When designing documentation for your own clinical service, established workflows like this can be useful references for what to collect and what the patient should receive.
A Pharmacist eCare Plan represents care information in a structured exchange format. Choosing the right goals and actions is the clinical documentation work; sending those data in the required format is a separate software and recipient requirement. The Pharmacist eCare Plan overview explains that exchange concept. A Word document or PDF bearing the same title doesn't establish that a recipient can import its information as structured data.
Reuse the structure and update the patient's decisions
A blank template saves repeated setup. A copied completed plan can carry forward an old goal, an unaccepted recommendation or a follow-up date that has already passed. At the next review, retain relevant history and update the current problem, agreed actions and result. Record a declined action as declined, with the patient's reason when relevant, rather than treating it as completed.
Software can help reuse the structure. For example, Healthie's template guidance describes applying a template and personalizing the resulting patient plan without changing the original. When evaluating a system, ask to see that distinction and how staff find the current plan after a later visit.
DocStation supports reusable note templates, patient goals and interventions, and notes attached to clinical records. Those features let a pharmacy keep the plan alongside the information used to make it.
