Chapter 4: Intake: Analysis of the Diet

Krause’s Food & NCP Book 14th Edition 2016

Batoul Ghosn
MSc Student in Nutritional Sciences in Tehran University of Medical Sciences (TUMS)
Email: Ghosn.Batoul@gmail.com 1
A database is a collection
of organized data,
information and records.
Database is information that a person needs in his
personal, business, social and religious life and the
power and purpose of information is not only in
collecting and finding them but more importantly
in using them.
Structured database Free-form database
It is also called the structured It is a loose collection of information,
data in which a record or file such as those you will find on the
of information arranged in World Wide Web. A collection of
uniform format. These your documents in the computer
databases are usually made from several programs can be
storage of information with considered as free-form database.
similar entries such as a list
of persons born in a country,
a medical database of
patients’ data, an inventory
database of a company and
many others.
Operational database Analytical database
It is a dynamic database that is It is a static database, where
used by any organization in its data is rarely modified.
day-to- day operation. They This database is often used to
are used to collect data, store and track historical data
maintain, modify and delete to make long term projections
data. and analysis.
•This model can be visualized as a
parent –child relationship wherein a
child may only have one parent but
parent can have several other
children.

•Another way of looking at this

model is by visualizing an inverted
tree. The single table acts as the
root of the inverted tree and the
other tables act as branches.

•To access the data from one of the

tables, one has to pass through the
root table. This model was popular
in the many IBM Information
Management Systems in the 1970s
using mainframe computers.
•This model was developed to
address in part the problems of the
hierarchical model. As with
heirarchical model, it could be
visualized as an inverted tree;
however, this model allows many
inverted tress sharing branches but
are still part of the same database
structure.

•As with the parent-child model, the

child is allowed to have multiple
parents. Unlike in the heirarchical
model access data begins from the
root table.

•In the network model, it allows

access of data from any table . This
model was eventually replaced by
the relational database model.
•Was developed by Dr. E. F. Codd of
IBM in the 1970s partly to solve the
problems of the earlier databse
models as well as finding a of
making database management less
dependent on any application.

•The terms relations, attributes

and domains are used frequently
in relational database models.

•A relation is a table with columns

& rows.
•Attributes are thje names given
to each colunm of the relation.
•Domain is the value with which
the
•attribute will take.

•A relational database is essentially

a collection of tables, and if a
databse is a collection of tables,
these tables are simply called
relations, hence, the name.
 Entity-relationship Object-relational
Model Dimensional Model model

This model was Is a specialized adaption Is a model that

using the relational utilizes the
written by Peter model that is used to
represent data in data relationship model
Chen in 1976. as well as the
warehouses.
This model is an object- oriented
abstract and Data warehouses is
programming
coceptual essentially storage of paradigm.
representation of all dgital data of a
company or
data. organization.
This model attempts to
In this model, a single
bring together
large table of database and
information is used application
using dimensions and programming closer
measures. Dimension together.
tells where, who and
what type while
measure would mean
quantity.
•RDBMS is designed to
create, maintain,
manipulate, modify
and delete information
in a relational
database.

•As previously
mentioned, moderm
database utilize the
relational database
model and many of
•today’s software
caters to this type of
Create a database
Information storage
Information retrieval
Information management
Information analysis
Print and share information
It is a number or
value found and
stored in the
database. Data is
static because it
remains the same
until it is modified
by a process.
It is a data that has been
processed thereby making
it. Relevant and meaningful
to the person viewing it..
Informationis dynamic
because it changes relative
to the data stored in the
database and it could be
processed in many ways.
It is used to represent a value
that is unknown or missing.
A null value is niether a zero
nor a blank.
•It is the main structure in
•the relational database. It
is composed of attributes
(fields) and domain
(records)
•A table almost always
represents a subject that
can be an object (person,
place, or thing) or an event.
It is an organized collection
of data about an entity. As
an example, for a
bookstore, a file
called “Branch” can
contain all the data
about a particular
bookstore branch.
It refers to a specific
person, place, thing, or
event. Record is also known
as the “tuple” in the
relational database
terminology. It pertains to
structure in the database
table representing a unique
instance of a subject.
•It is the smallest
structure of a data from
a larger database
structure in a relational
database
•A field can store data
in a database and
represent a character
opf the subject to
which database table it
resides.
It is also known as a virtual
table. It is called a virtual
table since it does not hold
data on its own; rather it
gets data from the table
which it is based. And since
it comes from other table it
is composed of several fields
coming from one or more
data.
•These are fields that serve
specific purposes within a
table. There are two types
of keys, the primary key
and the foriegn key .

•The Primary key is a field

that uniquely identifies a
record in the table.

•The Foreign key is a special

field that establishes a
relationship between two
tables.
They exist when two
or more tables have
connection or
association .
Primary key
Foreign key
Linking table is a table that establishes
a connection between two or more
tables
When two or more tables are related,
there exist between them a specific
type of relationship and there are
three types of possible relationships.
This relationship exist
between tables when
only one record of the
first table is related to
only one record to a
second table, and only
one record of the
second table is related
to only one record to
the first table.
•This relationship exist
between tables when one
record of the first table can
be related to one or more
records to a second table,
but only one record from
the second table can be
related to a single record in
the first table.

•This relationship is the most

common relationship that
exist between tables and
helps to reduce or eliminate
duplicate and redundant
data.
•This relationship exists
between tables when one
record of the first table can
be related to one or more
records to a second table
and one record drom the
second table can be related
to one or more records to
the first table.

•The connection between

the two tables will be
difficult to establish and will
resullt to redundant data in
one of the tables.
 Define the purpose of your database. Consider the questins or
queries you may want to answer about the stored data.
 Determine the tables that you need in the databse.
 Determine the fields that you need in the database.
 Identify unique fields values that you will allow Access to
connect information stored in a separate table.
 Determine the relationships between tables. A relationship works by
matching data in the key fields which is usually a field with the same
name in both tables.
 Test the design by entering the sample data. Check that you can run a
query on the database and get the information you want.
 Modify data is easy. Changes to the value of one field within the table
should not affect the values of the fields in the table.
 Retrieving information is easy. Extracting desired information from
tables with well defined relationships should make accessing and
retrieving data a lot faster.
 Developing and building user application is easy. Data manipulation
would be the main focus of programming and not solving the
problems associated with a poorly designed database.
 Maintaining the structure is easy. Changes made to any table. Or
columns should not affect other tables or columns.
 Adding and deleting data is easy.
Intake: Analysis of the Diet
 Data Analysis
• Turning raw data into useful information.
• Purpose is to provide answers to questions being asked at a
program site or research questions.
• Even the greatest amount and best quality data mean nothing if
not properly analyzed—or if not analyzed at all.
• Analysis is looking at the data in light of the questions you
need to answer:
– How would you analyze data to determine: “Is my program/research
meeting its objectives?”
 Answering Programmatic
Questions
• Question: Is my program meeting its objectives?
• Analysis: Compare program targets and actual program
performance to learn how far you are from target.
• Interpretation: Why you have or have not achieved the target and
what this means for your program.
• May require more information.
Data Preparation Process
Prepare preliminary plan of data analysis

Check questionnaires

Edit

Code

Transcribe

Clean data

Select a data analysis strategy
 Types of Statistical Analyses Used

• Data summarization: the process of describing a data matrix by

computing a small number of measures that characterize the data
set.
• Four functions of data summarization:
– Summarizes the data
– Applies understandable conceptualizations
– Communicates underlying patterns
– Generalizes sample findings to the population
Coding
• Coding – process of translating information gathered from
questionnaires or other sources into something that can be analyzed.
• Involves assigning a value to the information given— often value is given
a label.
• Coding can make data more consistent:
– Example: Question = Sex
– Answers = Male, Female, M, or F
– Coding will avoid inconsistencies
Coding System
• Common coding systems (code and label) for variables:
– 0=No 1=Yes
(1 = value assigned, Yes= label of value)
– OR: 1=No 2=Yes
• When you assign a value you must also make it clear what that value means.
– In first example above, 1=Yes but in second example 1=No
– As long as it is clear how the data are coded, either is fine
• You can make it clear by creating a data dictionary to accompany the
dataset.
Coding: Dummy Variable
• A “dummy” variable is any variable that is coded to have 2 levels
(yes/no, male/female, etc.)
• Dummy variables may be used to represent more complicated variables
– Example: No. of cigarettes smoked per week-- answers total 75
different responses ranging from 0 cigarettes to 3 packs per week.
– Can be recoded as a dummy variable: 1=smokes (at all)
0=non-smoker
• This type of coding is useful in later stages of analysis.
 Attaching Labels to values:
• Many analysis software packages allow you to attach a label to the variable values
Example: Label 0’s as male and 1’s as female
• Makes reading data output easier:

Without label: Variable SEX Frequency Percent

0 21 60%
1 14 40%

With label: Variable SEX Frequency Percent

Male 21 60%
Female 14 40%
Coding – Original Variables
• Coding process is similar with other categorical variables.
• Example: Variable EDUCATION, possible coding: 0 = Did not
graduate from high school
1 = High school graduate
2 = Some college or post-high school education 3 = College
graduate
• Could be coded in reverse order (0=college graduate, 3=did not
graduate high school).
• For this ordinal categorical variable we want to be consistent with
numbering because the value of the code assigned has significance.
• Example of bad coding:
0 = Some college or post-high school education 1 = High school
graduate
2 = College graduate
3 = Did not graduate from high school
• Data has an inherent order but coding does not follow that order—NOT
appropriate coding for an ordinal categorical variable.
 Nutrition status
• Degree to which physiologic nutrient needs are met for an individual.

• Assessment is the foundation of nutritional care, important base for

personalizing an individual’s nutritional care in the context of the cause,
prevention, or management of disease or promotion of health.

• Chronic diseases, as well as many gastrointestinal disorders and most cancers,

are influenced by the underlying nutritional status.
• Individual’s nutritional status affects gene expression.

• Regular assessment can detect a nutritional insufficiency in the early stages,

allowing nutrition support before a more severe deficiency and functional
change develops

• Nutrition assessment often begins with collection of dietary intake data.

• Then, they are analyzed for nutrient and phytonutrient content which is
compared with dietary recommendations and requirements particular to that
individual.
• Nutrition risk is determined through a nutrition screening process.

• The purpose of a nutrition screen is to quickly identify individuals who

are malnourished or at nutritional risk and determine whether a more
detailed assessment is warranted.
 Key considerations for nutrition screening include:
1. Tools should be quick, easy to use, and able to be conducted in any practice
setting.

2. Tools should be valid and reliable for the patient population or setting.

3. Tools and parameters are established by RDNs, but the screening process may
be performed by dietetic technicians, registered, or other trained personnel.

4. Screening and rescreening should occur within an appropriate time frame for the
setting
• The most common screening criteria include history of weight loss, current need
for nutrition support, presence of skin breakdown, poor dietary intake, and chronic
use of modified or unusual diets.

• The goal of screening is to identify individuals who are at nutritional risk, those
likely to become at nutritional risk, and those who need further assessment.
 Nutrition Screening Tools

• A screen that is simple to use is the Malnutrition Screening Tool (MST) by

Ferguson (1999).

• The tool is useful for the acute hospitalized adult population and was the only one
of the 11 evaluated by the EAL shown to be valid and reliable for identifying
problems in acute care and hospital- based ambulatory care settings (AND 2013b).
• Another screening tool is the Malnutrition Universal Screening Tool
(MUST) developed by Stratton and colleagues (2004) to assess for
malnutrition rapidly and completely for adults in the community; it is
designed to be used by professionals of different disciplines (AND,
2015).
Intake: Analysis of the
Diet
• The Nutrition Risk Screening (NRS 2002) is a screening tool that is useful
for medical-surgical hospitalized patients (AND, 2015).

• This tool contains the nutritional components of the MUST and a grading
of disease severity as reflected by increased nutritional requirements.
Intake: Analysis of the
Diet
• The Mini Nutritional Assessment (MNA) Short Form is a rapid and
reliable screening method for the subacute and ambulatory elderly
populations.
Intake: Analysis of the
Diet
 Nutrition assessment

• Nutrition assessment is a comprehensive evaluation carried out by an RDN

using medical and health, social, dietary and nutritional medication and
supplement and herbal use histories; physical examination; anthropometric
measurements; and laboratory data.

• Nutrition assessment interprets data from the nutrition screen and incorporates
additional information.

• It is the first step in the nutrition care process.

 Tools for Assessment of Nutritional Status

• Several tools are available for the assessment of nutritional status.

• The Subjective Global Assessment (SGA).

• The Mini Nutrition Assessment long form (MNA)

Intake: Analysis of the
Diet
 History

• Medical or Health History

• Medication and Herbal Use History
• Social History
• Nutrition or Diet History
Intake: Analysis of the t
Die
Intake: Analysis of the
Diet
• Dietary intake data may be assessed either by collecting:

• Retrospective intake data (e.g., a 24- hour recall or food

frequency questionnaire)
• Prospective intake data (e.g., a food record kept for a number of days by an
individual or the caretaker).
• A daily food record, or food diary, involves documenting dietary intake as it
occurs and is often used in outpatient clinic settings.

• Usually completed by the individual client.

• Usually most accurate if the food and amounts eaten are recorded at the time of
consumption, minimizing error from incomplete memory or attention.

• The individual’s nutrient intake is then calculated and averaged at the end of the
desired period, usually 3 to 7 days, and compared with dietary reference intakes
(DRIs) government dietary guidelines as in the MyPlate guide, or personalized
dietary recommendations for disease management or prevention
Intake: Analysis of the
Diet
• The food frequency questionnaire is a retrospective review of intake based on
frequency (i.e., food consumed per day, per week, or per month).

• Food frequency chart organizes foods into groups that have common
nutrients.

• Focus of the food frequency questionnaire is the frequency of consumption

of food groups without portion sizes, so cannot be applied to certain
nutrients.

• Helpful to complete food frequency questionnaires for the period

immediately before hospitalization or before illness to obtain a complete
and accurate history.
• The 24-hour recall method of data collection requires individuals to remember the
specific foods and amounts of foods they consumed in the past 24 hours.

• Using a specific set of questions to gain as much detailed information as possible.

• Problems commonly associated:

(1) an inability to recall accurately the kinds and amounts of food eaten,

(2) difficulty in determining whether the day being recalled represents an individual’s
typical intake or was exceptional,

(3)the tendency for persons to exaggerate low intakes and underreport high intakes
of foods.
• Concurrent use of food frequency questionnaires with 24-hour recalls or food
diaries improves the accuracy of dietary intake data.

• The validity of dietary recall information from obese individuals is often

questionable, because they tend to underreport their intakes.

• The same can be true for patients with eating disorders, those who are critically
ill, those who abuse drugs or alcohol individuals who are confused, and those
whose intake is unpredictable.
 Nutrient Intake
•
Analysis
The NIA is a tool used in various inpatient settings to identify nutritional
inadequacies by monitoring intakes before deficiencies develop.

• Information about actual intake is collected through direct observation

or an
inventory of foods eaten based on observation of what remains on the
individual’s tray or plate after a meal.

• In many cases, photographs taken by smartphones are useful in documenting

amount of food consumed (LaGesse, 2011).

• Intake from enteral and parenteral tube feedings is also recorded.

• A NIA should be recorded for at least 72 hours to reflect daily variations in
intake.

• Complete records for this period usually accurately reflect an average intake for
most individuals.

• If the record is incomplete, it may be necessary to extend the duration of the

recorded intake.

• Eating habits or meals consumed during the weekend and during the week
may differ, so ideally a weekend day is included.
 Analysis of Dietary Intake Data

• Once all data has been collected, the record of total intake can be analyzed for its
nutrient content using one of several available computerized methods.

• Several database choices for estimation of intake vary by the nutrients analyzed,
other data factored in, and how the data are presented.
• For example, besides the amounts of various nutrients:

1 Are the data presented for each day in addition to an average for the week?

2Is information on the individual’s gender, height, weight, and age factored in
so that the data can be compared with the DRI for that individual?

3Or are the food intake data general (as from a completed food frequency
questionnaire) and can be compared only with MyPlate.com or other
general guidelines
 Nutrient Databases
• The USDA National Nutrient Database for Standard Reference (SR), which
is maintained by the Agricultural Research Service (ARS) of the U.S.
Department of Agriculture, is updated annually.

• The SR is the major source of food composition data in the United States, and,
as of this writing, is at version SR27 (USDA ARS, 2014; Pennington, 2007).

• The Food and Nutrient Database for Dietary Studies (FNDDS), also
maintained by the ARS, is a database of foods, their nutrient values, and
weights for typical food portions.
• It includes 10 data files, plus comprehensive documentation and a user’s guide
for ease of use.

• The FNDDS is used to analyze data from the survey “What We Eat in
America,” the dietary intake component of the National Health and Nutrition
Examination Survey (NHANES).

• The FDA Total Diet Study Database includes 280 core foods. It provides
analytical data for dietary minerals, folic acid, heavy metals, radionuclides,
pesticide residues, industrial chemicals, and chemical contaminants.
 Intake: Analysis of the Diet
• The Dietary Supplements Database from the NIH Office of Dietary
Supplements offers information on dietary supplements via its website and its
My Dietary Supplements (MYDS) mobile application.

• The Nutrient Data System for Research from the University of Minnesota
provides ongoing updates for generic and branded products, as well as a
dietary supplement assessment module.

• The ProNutra database, from VioCare, Inc., is designed for research diets
controlled in many nutrients. It includes customizable calculation algorithms,
with research kitchen outputs (Viocare, 2009).
• Food and nutrition management software systems such as Computrition or
CBORD are designed for institutional use and typically include extensive nutrient
databases.

• These systems may regularly import data from the SR.

• Only certain software programs are approved for use in the USDA School Meals
program
NUTRITIONAL DATA ANALYSIS
SOFTWARE AND APPLICATIONS
PREAMBLE
 Physical nutritional assessment &Laboratory
analysis
Traditionally, nutritional assessment was done manually by
physical assessment, Data analysis was also done by
calculating variables manually
food companies would send food samples to laboratories for
chemical testing. Chemical testing involves the incineration
of the foods to test the ash for exact nutritional content.
Nutritional Software
 Nutritional Software
 Software are available as alternative to laboratory nutrition analysis and
physical nutritional assessment. They provide quick computations of
nutritional assessment variable. Other software utilizes a database of
ingredients that have previously been laboratory tested.
 The user can input ingredient data by matching their ingredients to
ingredients found in the database; the analysis can then be calculated.
 In case of anthropometric assessment the user can compute the
required data and nutritional status of an individual or groups will be
indicated by the specific software program
 Example of nutritional software are; WHO-anthro, WHOanthro
plus, Nutri-survey, Ena, Epi-INFO, SMART etc
ENA
What does ENA stand for?
The acronym ‘ENA’ stands for Emergency Nutrition
Assessment. The original name of the software
associated to the SMART initiative was ‘Nutrisurvey’ but
the name was subsequently changed to ENA to
differentiate it better from the general nutrition
software called NutriSurvey.
The purpose of ENA for SMART is to make nutrition
assessments and mortality rate calculations in emergency
situations as easy and reliable as possible. To achieve this
it focuses on the most important indicators
(anthropometric and mortality data)
ENA cont…..
 Epi Info
Epi Info is a public domain statistical software for epidemiology which has been
developed by Centers for Disease Control and Prevention.
Epi Info allows epidemiologists and other public health and medical professionals
to easily and quickly develop a questionnaire or form, customize the data entry
process, check the survey data for outliers and inconsistent data, conduct a
descriptive analysis of survey data, and easily generate output files from the
analysis.
The program allows for electronic survey creation, data entry, and analysis. Within
the analysis module, analytic routines include t-tests, ANOVA, nonparametric
statistics, cross tabulations and stratification with estimates of odds ratios, risk
ratios, and risk differences, logistic regression (conditional and unconditional),
survival analysis and analysis of complex survey data.
Epi Info
WHO Anthro & WHO Anthro plus
On the use of the WHO Anthro: Software for assessing growth
and development of the world's children(0-5)yrs. The software
consists of three modules:
Anthropometric calculator
Individual assessment
Nutritional survey
WHO anthroPlus
 WHO anthroplus is the same as WHO anthro except in the age
categories.
WHO AnthroPlus is a software for the global application of the WHO
Reference 2007 for 5-19 years to monitor the growth of school-age
children and adolescents. To show the continuity with the WHO Child
Growth Standards for 0-5 years these are included in AnthroPlus for
the three indicators that apply.
The software opens by default in English but can be changed to run in
French, Spanish and Russian. It consists of the following modules:
- Anthropometric calculator
- Individual assessment
- Nutritional survey
Anthroprometric calculator
It consists of
Height for age,-stand for stunting
Weight for age-stand for wasting
BMI for age-stand for
Computed in terms of percentile, and analyzed in terms of Z
score
Macros for the statistical software packages SPSS, SAS,
S-Plus and STATA to facilitate survey data analysis.
All four macros, i.e. the SAS, S-Plus, SPSS and STATA
macro calculate the indicators of the attained growth
standards (length/height-for-age, weight-for-age, weight-
for-length, weight-for-height, body mass index-for-age, head
circumference-for-age, arm circumference-for-age, triceps
skinfold-for-age and subscapular skinfold-for-age).
Macros ….
SAS (Statistical Analysis System) is an integrated system of
software products provided by SAS Institute Inc.. that
enables programmers to perform:
Report writing and graphics
Quality improvement
Statistical analysis
Business planning and fore casting
Project management
Macros….
Stata is a general-purpose statistical software package created in
1985 by StataCorp. It is used by many businesses and academic
institutions around the world. Most of its users work in research,
especially in the fields
of economics, sociology, political science,
biomedicine andepidemiology
Stata's capabilities includes data management, statistical
analysis, graphics, simulations, and custom programming.
S-PLUS is a commercial implementation of the S
programming language sold by TIBCO Software Inc..
It features object-oriented programming capabilities and
advanced analytical algorithms.
Macros…
SPSS, refer back to spss features and applications
Z-score
In statistics, a standard score indicates how
many standard deviations an observation or datum is above
or below the mean.
Z-score…

The WHO Global Database on Child Growth and Malnutrition

uses a Z-score cut-off point of <-2 SD to classify low weight-
for-age, low height-for-age and low weight-for-height as
moderate and severe under nutrition, and <-3 SD to define
severe under nutrition. The cut-off point of >+2 SD classifies
high weight-for- height as overweight in children.
clinicians or researchers can assess the child’s growth and
general nutritional status by using a standardized age- and sex-
specific growth reference to calculate height-for-age Z- scores
(HAZ), weight-for-age Z-scores (WAZ), weight-for- height Z-scores
(WHZ) and body-mass-index-for-age Z- scores (BAZ).
The Z-score system expresses anthropometric values as several
standard deviations (SDs) below or above the reference mean or
median value. Because theZ-score scale is linear, summary
statistics such as means, SDs and standard errors can be
computed from Z-score values. Z- score summary statistics are
also helpful for grouping growth data by age and sex
Patient Data Analysis
 Core Elements

• Medication therapy review (MTR)

• Personal medication record (PMR)
• Medication-related action plan (MAP)
• Intervention and/or referral
• Documentation and follow-up
 Medication Therapy Review

• The medication therapy review (MTR) is a systematic

process of collecting patient- specific information, assessing
medication therapies to identify medication-related
problems, developing a prioritized list of medication-related
problems, and creating a plan to resolve them.
 The MTR may include the following:
• Interviewing the patient to gather data including demographic information, general health and activity
status, medical history, medication history, immunization history, and patients’ thoughts or feelings
about their conditions and medication use
• Assessing, on the basis of all relevant clinical information available to the pharmacist, the patient’s
physical and overall health status, including current and previous diseases or conditions
• Assessing the patient’s values, preferences, quality of life, and goals of therapy

• Assessing cultural issues, education level, language barriers, literacy level, and other characteristics
of the patient’s communication abilities that could affect outcomes
• Evaluating the patient to detect symptoms that could be attributed to adverse events caused by any
of his or her current medications
• Interpreting, monitoring, and assessing patient’s laboratory results
• Assessing, identifying, and prioritizing medication
related problems related to

» Adherence to the therapy

» Untreated diseases or conditions
» Medication cost considerations
» Healthcare/medication access considerations
• Developing a plan for resolving each medication related problem
identified
• Providing education and training on the appropriate use of
medications and monitoring devices and the importance of
medication adherence and understanding treatment goals
• Coaching patients to be empowered to manage their
medications
• Monitoring and evaluating the patient’s response to therapy,
including safety and effectiveness
 Personal Medication Record

• The personal medication record (PMR) is a comprehensive

record of the patient’s medications (prescription and
nonprescription medications, herbal products, and other
dietary supplements)
The PMR, which is intended for use by the patient, may include the following information
• Patient name
• Patient birth date
• Patient phone number
• Emergency contact information (Name, relationship, phone number)
• Primary care physician (Name and phone number)
• Pharmacy/pharmacist (Name and phone number)
• Allergies (e.g., What allergies do I have? What happened when I had the allergy or
reaction?)
• Other medication-related problems (e.g., What medication caused the problem? What
was the problem I had?)
• Potential questions for patients to ask about their medications (e.g., When you are
prescribed a new drug, ask your doctor or pharmacist...)
• Date last updated
• Date last reviewed by the pharmacist, physician, or other healthcare
professional
• Patient’s signature
• Healthcare provider’s signature
• For each medication, inclusion of the following:
» Medication (e.g., drug name and dose)
» Indication (e.g., Take for…)
» Instructions for use (e.g., When do I take it?)
» Start date
» Stop date
» Ordering prescriber/contact information (e.g., doctor)
» Special instructions
 Medication-Related Action Plan

The medication-related action plan (MAP) is a patient-centric

document containing a list of actions for the patient to use
in tracking progress for self-management.
The MAP, which is intended for use by the patient, may include the
following information:
• Patient name
• Primary care physician (Doctor’s name and phone number)
• Pharmacy/pharmacist (Pharmacy name/pharmacist name
and phone number)
• Date of MAP creation (Date prepared)
• Action steps for the patient: “What I need to do...”
• Notes for the patient: ”What I did and when I did it...”
• Appointment information for follow-up with pharmacist, if
applicable
 Intervention and/or Referral
The pharmacist provides consultative services and intervenes to address medication-
related problems; when necessary, the pharmacist refers the patient to a physician or
other healthcare professional.
Examples of circumstances that may require referral
include the following:
•A patient may exhibit potential problems discovered during the MTR that may
necessitate referral for evaluation and diagnosis

•A patient may require disease management education to help him or her manage
chronic diseases such as diabetes

•A patient may require monitoring for high-risk medications (e.g., warfarin,

phenytoin, methotrexate)
 Documentation and Follow-up

MTM services are documented in a consistent manner, and a follow-

up MTM visit is scheduled based on the patient’s medication-
related needs, or the patient is transitioned from one care setting
to another.

Documentation is an essential element of the MTM service model.

The pharmacist documents services and intervention(s)
performed in a manner appropriate for evaluating patient
progress and sufficient for billing purposes.
Proper documentation of MTM services may serve several purposes
including, but not limited, to the following:

•Facilitating communication between the pharmacist and the patient’s other

healthcare professionals regarding recommendations intended to resolve or
monitor actual or potential medication-related problems
• Improving patient care and outcomes
• Enhancing the continuity of patient care among providers and care
settings
•Ensuring compliance with laws and regulations for the maintenance of patient
records
• Protecting against professional liability
• Capturing services provided for justification of billing or
reimbursement (e.g., payer audits)
• Demonstrating the value of pharmacist-provided MTM services
• Demonstrating clinical, economic, and humanistic outcomes
 Follow-up
When a patient’s care setting changes (e.g., hospital admission, hospital to home, hospital to
long-term care facility, home to long- term care facility), the pharmacist transitions the
patient to another pharmacist in the patient’s new care setting to facilitate continued MTM
services. In these situations, the initial pharmacist providing MTM services participates
cooperatively with the patient’s new pharmacist provider to facilitate the coordinated
transition of the patient, including the transfer of relevant medication and other health-
related information. If the patient will be remaining in the same care setting, the pharmacist
should arrange for consistent follow-up MTM services in accordance with the patient’s
unique medication-related needs. All follow-up evaluations and interactions with the
patient and his or her other healthcare professional(s) should be included in MTM
documentation.