Download Internal Medicine/Clinical Teaching Unit Rotation

Internal Medicine/Clinical Teaching Unit Rotation
Primary Preceptor Contact Info: Jennifer Hawkes
Phone 250-565-2014
Email [email protected]
Pager 561-6501
Rotation & length: 6 weeks
Preceptor(s):
Jennifer Hawkes
Barb Falkner
Dates of Rotation:
This rotation will be completed on the Internal Medicine Unit and the Clinical Teaching Unit (provide care for patients throughout the
hospital with a focus on internal medicine for this rotation). Your preceptor will provide assistance to you in the provision of
pharmaceutical care for your patients.
Patients requiring acute care are usually admitted under an internist or emergency room doctor to the internal medicine unit. The
internal medicine unit also receives “step down” patients from the Intensive Care Unit. These patients have a wide variety of medical
conditions and also often have coexisting illnesses and multiple drug regimens. Often other specialists will be consulted by the
internist and will be involved with the care of one disease.
The Clinical Teaching Unit usually has 25-30 patients and involves an overseeing internist (rotates on a weekly basis), a senior
resident (rotates on a monthly basis – involved with all patients), family practice residents (see 5-6 patients daily) and clinical clerks
(third year medical students – see 3-4 patients daily). The team sees patients individually and rounds together. Educational
discussions are also incorporated. The team meets at 7:45 am on the 5th floor to hand-off new patients post call, then at 9am in the
ground floor conference room (behind switchboard) for rounds – these rounds may include a teaching session and/or case
presentations of patients. Lastly the team meets at 5:30 pm. The meeting schedules may change depending on the internist/senior
resident.
Goal:
The resident shall develop the knowledge and skills necessary to provide direct patient care using pharmaceutical care principles.
You should be familiar with your patient, their labs, vitals and medications on a daily basis. When presenting the patient to
your preceptor(s) it should be done in an systematic way (pt ID, chief complaint (on presentation and of the day if patient
has been in hospital for many days), history of present illness (from past to present history), working diagnosis, past
medical history, social history, family history, allergies, medications, review of systems, listing and prioritizing of DRP’s
and work-up of at least the most important DRP (includes listing and rationalizing of therapeutic alternatives and specific
recommendation – drug, dose, route, frequency, monitoring parameters, non-drug therapy and education). You are
expected to write chart notes (SOAP style if applicable) for interventions that you make ie) pt counseling, pharmacy
consults, drug levels, and therapy changes that you have initiated or feel need adapting. All plans/recommendations
should be discussed with the team (pt, dr, nurse) prior to writing the note unless not available.
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Objectives Summary
Enhance skills in patient interviews and counseling
Develop a patient database
Identify patients most likely to experience drug-related problems (DRPs)
Enhance skills in prioritizing DRPs
Develop and implement pharmacy care plans
Follow-up and evaluate patient outcomes
Document pharmaceutical care activities in the health record
Use knowledge of diseases, medications and complications to enhance pharmaceutical care
Apply basic principles of pharmacokinetics and laboratory test interpretation in the care of patients
Provide drug information
Use evidence-based knowledge of traditional as well as emerging and/or controversial therapeutic
alternatives in the development of pharmacy care plans
Objectives:
1. The objectives and activities for direct patient care rotations must be met.
2. The general objectives and activities for practice foundation skills will apply to this rotation.
3. The resident will demonstrate knowledge of the common disease states seen in this patient population.
Expected Outcome:
The resident will be able to:
 Define disease state and risk factors
 Head to toe pathophysiology and symptoms
 Basic understanding of diagnosis
 General Management
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For the following diseases apply the above knowledge to the pharmaceutical care of your patients:
 Angina [Chronic Stable (CAD) and Unstable (NSTEMI)]
 Myocardial Infarction (STEMI)
 Hypertension
 Dyslipidemia
 Endocarditis
 Meningitis
 Pneumonia
 Osetomyelitis
 Atrial fibrillation/flutter (Acute and Chronic)
 Congestive Heart Failure (Acute Exacerbations and Chronic)
 Tuberculosis
 HIV
4. The resident will demonstrate knowledge of the therapeutic alternatives used in this patient population.
Expected Outcome:
The resident will be able to:
 For each of the disease states encountered on rotation, describe and compare traditional and emerging therapeutic
alternatives and apply this knowledge to the pharmaceutical care of the patients encountered.
5. The resident will demonstrate knowledge of the pharmacotherapy used in this patient population.
Expected Outcome:
The resident will be able to:
 For each of the drugs encountered during this rotation, discuss:
 Drug class
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Mechanism
Effectiveness / non-drug options
Dose/ route/ frequency/ duration/ convenience / economics
Onset/peak/duration/elimination (and factors affecting)
Head to toe side effects/ Contraindications / Interactions
Monitoring (what, frequency, duration, by whom)
Some of the medications you may encounter include:
 Beta blockers
 ACE Inh
 ARBs
 Statins
 Calcium Channel Blockers
 Aspirin
 Clopidogrel
 Warfarin
 Nicotine Replacement Therapy
 Nitroglycerin
 Various Antibiotics (including Gentamicin and Vancomycin)
 Digoxin
 Amiodarone
6. The resident will demonstrate knowledge of the complications seen in this patient population.
Expected Outcome:
The resident will be able to:
 Define the complication and risk factors
 Head to toe pathophysiology and symptoms
 Prevention
 General Management
 Monitoring (what, frequency, duration, by whom)
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For the following complications apply the above knowledge to the pharmaceutical care of your patients:
 Swallowing difficulties
 Withdrawal symptoms
 Drug accumulations
 Fluid and Electrolyte disturbances
Additional Activities:
Activities
Observe a MIBI stress test, MUGA, ECHO or other nuclear medicine
procedure
Kinetics calculations for gentamicin
Kinetics calculations for vancomycin
Interpret digoxin levels
Completed
Expectations:
1. The resident is expected to work 8 am – 4 pm Monday – Friday. The CTU rounds are from 9-11am Monday – Friday and the
resident is expected to be prepared and familiar with his/her patients by this time and contribute to rounds. IMU rounds are
8:45 am Monday – Friday. The resident may alternate rounds with CTU and IMU as discussed with the preceptor. The
resident may spend one night on call with a CTU resident.
2. The resident will dress professionally when in the clinic. Lab coat is mandatory while on patient care wards. Clothing is
professional. (No bare midriffs, no open toed shoes.)
3. Patients will be assigned to the resident on a daily basis based on the experience of the resident and progress through the
rotation. Residents are expected to look after 2-4 new patients daily, depending on the stage of the rotation in the year,
experience of the resident and complexity of the patients. It is important for the resident to advise the preceptor of workload
issues (if they are feeling overwhelmed or underutilized). It is important that the resident advise the preceptor if they feel they
are being asked questions beyond their skill level.
4. The resident will meet with the preceptor daily to review patients and discuss topics as agreed upon in advance with the
preceptor. The resident should prepare for topic discussions using readings supplied by the preceptor and by researching the
topic on their own. The resident should be prepared to discuss what they know about the topic, rather than receive a lecture
from the preceptor.
5. The resident will not provide any recommendation to patients, nurses or physicians without first discussing that
recommendation with the preceptor first, until directed otherwise by the preceptor.
6. All encounters with patients will be documented in the progress notes of the patient’s chart following a SOAP note format.
Initially, all notes must be reviewed with the preceptor prior to being written in the chart. After the preceptor is satisfied with
the quality of the notes, residents may write notes without first reviewing them with the preceptor but must alert the preceptor
to the patient’s chart note so that it may be reviewed.
Daily:
1. Ensure your pager is turned on – contact your preceptor if your pager is not functioning and obtain a temporary pager
from Marianna
2. Review patient load from CTU list and prioritize – review with your preceptor if you are unsure
3. The level of pharmaceutical care for each patient can vary – all patients need to have a care plan and monitoring
parameters with DRPs documented (Progress notes may be appropriate to write in addition to your care plan.)
4. Attend CTU rounds – daily to start, then as time permits
5. Visit patient daily for acute DRPs, twice weekly for less acute DRPs
6. Contact preceptor freely throughout day regarding questions or problems – if you are unsure if the outcome of an issue
could affect patient care - ASK
7. Meet at 1pm daily(2pm if discussion for the day is not finished) to review patients
8. If a patient is still in the hospital and you are not following them anymore – pass on your care plan profile to the
appropriate pharmacist who can continue to follow your patient.
Readings:
Refer to the S:Drive for most up to date readings. The following is a list of required and optional readings. The preceptor will give
readings for a topic at least one week prior to the discussion. It is understood that a tertiary reference such as DiPiro or Koda Kimble
will also be reviewed.
Internal Medicine Pharmacy Resident Readings as of June 8, 2007
Fluids and Electrolytes:
1) Sica DA, Nunley JR. Fluids and Electrolytes. In: Drug Therapy in Emergency Medicine.: 149-81.
2) Duane Bates. Lyte Review. Presented in Sept 2001.
3) Sharon Yamashita. Fluids and Electrolytes: A Practical Approach. Presented in 2005.
4) Lau A, Chan LN. Electrolytes, Other Minerals, and Trace Elements. In: Basic Skills in Interpreting Laboratory Data.: 183-97, 199-214.
Angina:
1) Dobesh PP. Management of Chronic Stable Angina. In: Pharmacotherapy Self-Assessment Program. 5th ed.: 237-74.
2) Smith SC, Goldberg AC. Ischemic Heart Disease. In: Stable Angina.: 96-105.
3) Nappi J, Spencer AP. Chronic Management of Coronary Artery Disease. In: Pharmacotherapy Self-Assessment Program. 4th ed. Kansas City: American
College of Clinical Pharmacy.; 2002: 123-55.
4) Kannam JP, Aroesty JM, Gersh BJ. Calcium Channel Blockers in the Management of Stable Angina Pectoris. Up to Date.
Myocardial Infarction:
1) Dobesh PP. Prevention of Cardiovascular Disease. In: Pharmacotherapy Self-Assessment Program. 5th ed.: 107-28.
2) Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA Guidelines for the Management of Patients With ST-Elevation
Myocardial Infarction-Executive Summary. Circulation 2004:1-49.
3) Spinler SA. Acute Coronary Syndromes. In: Pharmacotherapy Self-Assessment Program. 5th ed.: 1-40.
4) Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al, eds. Management of Patients With Unstable Angina and Non-STSegment Elevation Myocardial Infarction. A Report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines.: ACC/AHA.; 2002.
5) Reeder GS. Angiotensin converting enzyme inhibitors and receptor blockers in acute myocardial infarction: Recommendations for use. Up to Date.
6) Jorgenson D, Regier L. Post-MI: Troubleshooting Practical Issues. In: Rx Files.; 2004.
7) Heart Disease Risk Assessment. Providence Health Care. St. Pauls.
8) Uncomplicated MI. In: Dipiro.
9) Recommendations for Pharmacologic and Lifestyle Interventions in Patients Who Have Undergone CABG.
10) Information Pamphlet: Why AM I Taking So Many Pills After My Heart Attack.: Health Quality Council.
11) Roussin A, Bormanis J, Green M, Lam J. Post Myocardial Infarction.: The Thrombosis Interest Group of Canada.
12) Cheng JW. Recognition, pathophysiology, and management of acute myocardial infarction. AM J Health-Syst Pharm 2001;58:1709-18.
13) Rihn TL, Vanscoy GJ. Combination antithrombotic therapy in acute myocardial infarction. Am J Health-Syst Pharm 2002;59:1882-85.
14) Improving the Quality of Heart Attack Care.: Health Quality Council.; 2004.
Atrial Fibrillation/Flutter:
1) Hart RG, Halperin JL, Pearce LA, Anderson DC, Kronmal RA, McBride R, et al. Lessons from the Stroke Prevention in Atrial Fibrillation Trials. Am
College of Physicians 2003;138(10):831-39.
2) Albers GW, Dalen JE, Laupacis A, Manning WJ, Petersen P, Singer DE. Antithrombotic Therapy in Atrial Fibrillation. Chest 2001;119(1):194S-206S.
3) Arrhythmias. Dipiro.: 279-80, 283-84.
4) Drugs Affecting Renal and Cardiovascular Function. In: Goodman and Gillman. 10 th ed.: 952-3.
5) Richard Slavik. Controversies in Atrial Fibrillation. Presented in 2003.
6) Fuster V, Ryden LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, et al. ACC/AHS/ESC Guidelines for the Management of Patients with Atrial
Fibrillation: Executive Summary. Circulation 2001: 2118-50.
7) Sanoski CA. Chronic Arrhythmia Management. In: Pharmacotherapy Self-Assessment Program. 5th ed.: 191-233.
8) Table: Pharmacokinetic Characteristics and Doses of Antiarrhythmic Drugs.
9) Colette Raymond. Ibutilide for atrial fibrillation and flutter. Presented On April 18, 2001.
10) Cardiac and Vascular Disorders. KK.: 18-2.
11) Jennifer Lawerence. Atrial Fibrillation and Cardioversion. Presented On April 19, 2005.
12) Cheng JW. Acute Management of Arrhythmia. In: Pharmacotherapy Self-Assessment Program. 5th ed.: 41-66.
Dyslipidemia:
1) White CM, McBride BF, Kalus JS. Dyslipidemias. In: Pharmacotherapy Self-Assessment Program. 5th ed.: 165-89.
2) Genest J, Frohlich J, Fodor G, McPerson R. Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: 2003
update. CMAJ 2003;169(9):Online1-9.
3) Grundy SM, Becker D, Clark LT, Cooper RS, Denke MA, Howard J, et al. Executive Summary of the Third Report of the National Cholesterol
Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285(19):24862497.
4) Diabetes and Dyslipidemias. BC Community Drug Utilization Program.; 2006.
5) Shaver K. NCEP Cholesterol Guidelines. In: Pharmacists Letter 2001;17:1-5.
6) ATP III Guidelines At-A-Glance Quick Desk Reference. National Cholesterol Education Program.
7) LaRosa JC, Grundy S, Waters DD, Shear C, Barter P, Fruchart JC, et al. Intensive Lipid Lowering with Artorvastatin in Patients with Stable Coronary
Disease. MEJM 2005;352:Larosa1-11.
Congestive Heart Failure:
1) LaForest SK. Decompensated and Advanced Heart Failure. In: Pharmacotherapy Self-Assessment Program. 5th ed.: 67-104.
2) Fonarow GC, Weber JE. Rapid Clinical Assessment of Hemodynamic Profiles and Targeted Treatment of Patients with Acutely Decompensated Heart
Failure. Clinical Cardiology 2004;27:V1-23.
3) Jessup M, Brozena S. Heart Failure. NEJM 2003;248(20):2007-18.
4) Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A. et al. The Effect of Spironolactone on Morbidity and Mortality in Patients with Severe
Heart Failure. NEJM 1999;341(10):709-717.
5) Smith TW, Morgan JP. Actions of angiotensin II on the heart. UpToDate.
6) Colucci WS. Pathophysiology of heart failure: Neurohumoral adaptations. UpToDate.
7) Shilpak MG. Pharmacotherapy for Heart Failure in Patients with Renal Insufficiency. Annals of Internal Medicine 2003;138(11):917-23.
8) Eichhorn EJ. Restoring Function in Failing Hearts: The Effects of Beta Blockers. The American Journal of Medicine 1998;104:163-69.
9) Karen Sidhu. Antithrombotics in Heart Failure. Presented On March 18, 2005.
Hypertension:
1) Canadian Hypertension Education Program Recommendations.; 2006.
2) K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease. Executive Summary.; 2002.
3) Table: Preferred Antihypertensive Agents for CVD.
4) Canadian Recommendations for the management of hypertension.; 2005.
5) Carter BL, Zillich AJ. Management of Hypertension. In: Pharmacotherapy Self-Assessment Program. 5th ed.: 129-63.
6) Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, et al. The Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure. JAMA 2003;289(19):2560-72.
7) Wendy Gordon. Update on the Management of Hypertension. Presented In March 2004.
Total Parenteral Nutrition:
1) Chan-Yan C. Therapeutic Guidelines – Electrolyte Replacement Phosphates
2) Dana Cole. Handout: TPN Basics.
3) Interpreting TPN. Handout.
4) Btaiche IF, Khalidi N. Metabolic complications of parenteral nutrition in adults, part 1. Am J Health-Syst Phar 2004;61:1938-49.
5) Btaiche IF, Khalidi N. Metabolic complications of parenteral nutrition in adults, part 2. Am J Health-Syst Phar 2004;61:2050-9.
6) Berger R, Adams L. Critical Care: Nutritional Support in the Critical Care Setting (Part 1). Chest 1989;96(1):139-50.
7) Berger R, Adams L. Critical Care: Nutritional Support in the Critical Care Setting (Part 2). Chest 1989;96(2):372-80.
8) J. Greenwood. Phar 501 – Advanced Pharmacotherapeutics Nutritional Assessment. Presented in 1997.
Feeding Tubes:
1) Thomson FC, Naysmith MR, Lindsay SA. Managing drug therapy in patients receiving enteral and parenteral nutrition. Hospital Pharmacists
2000;7(6):155.
2) Medication Administration. Clinical Guidelines on Enteral Tube Feeding.
3) Troubleshooting Guide for Nasogastric Feeding Tubes. Novartis Nutrition Corporation.; 2003.
Acid/Base:
1) Acid-Base Disorders Worksheet.
2) Blood Gas and Acid Base Evaluations.
Renal:
1) Renal Function Assessment Worksheet.
2) Kappel J, Calissi P. Nephrology: 3. Safe drug prescribing for patients with renal insufficiency. CMAJ 2002;166(4):473-7.
ETOH Withdrawal:
1) Alcohol Withdrawal Syndrome. In: Clinical Assessment and Pharmacology.: 266-80.
Hepatic Encephalopathy:
1) Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, et al. Beta-Blockers to Prevent Gastroesophageal Varices in Patients with
Cirrohosis. NEJM 2005;353(21):2254-61.
Mid-Point Evaluation - Internal Medicine/Clinical Teaching Unit Rotation
Formative Preceptor Evaluation
Resident:
Preceptor(s):
Rotation:
Dates of Rotation:
Assess the resident’s achievement of the objectives, giving specific examples of unsatisfactory performance.
Standard
The resident shall develop the knowledge and skills necessary to provide direct patient care using pharmaceutical care principles.
Learning Objectives and Expected Outcomes
1. The resident will demonstrate knowledge of the common disease states seen
in this patient population. Define disease state and risk factors, head to toe
pathophysiology and symptoms, basic understanding of diagnosis & general
management of the following:
 Angina [Chronic Stable (CAD) and Unstable (NSTEMI)]
 Myocardial Infarction (STEMI)
 Hypertension
 Dyslipidemia
 Diabetic Ketoacidosis
 Endocarditis
 Meningitis
 Pneumonia
 Osetomyelitis
 Atrial fibrillation/flutter (Acute and Chronic)
 Congestive Heart Failure (Acute Exacerbations and Chronic)
 Tubuculosis
Narrative Commentary
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HIV
Seizure disorder
2. The resident will demonstrate knowledge of the therapeutic alternatives
used in this patient population. Describe and compare traditional and
emerging therapeutic alternatives.
3. The resident will demonstrate knowledge of the pharmacotherapy used in
this patient population. Discuss: drug class, mechanism, effectiveness/ nondrug options, dose/ route/ frequency/ duration/ convenience/ economics,
onset/ peak/ duration /elimination (and factors affecting), head to toe side
effects/contraindications/interactions, monitoring (what, frequency, duration,
by whom).
 Beta blockers
 ACE Inh
 ARBs
 Statins
 Calcium Channel Blockers
 Aspirin
 Clopidogrel
 Warfarin
 Nicotine Replacement Therapy
 Nitroglycerin
 Various Antibiotics (including Gentamicin and Vancomycin)
 Digoxin
 Amiodarone
4. The resident will demonstrate knowledge of the complications seen in this
patient population. Define the complication and risk factors, head to toe
pathophysiology and symptoms, prevention, general management, monitoring
(what, frequency, duration, by whom).
 Swallowing difficulties
 Withdrawal symptoms
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Drug accumulations
Fluid and Electrolyte disturbances
A. Direct Patient Care
Standard: The resident shall develop the knowledge and skills necessary to provide direct patient care using pharmaceutical care
principles.
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Learning Objectives and Expected Outcomes
Narrative Commentary
1. The resident will develop the skills necessary to identify, prevent and resolve
drug-related problems.
 Develop a patient database from the health records, the patient or family
members, and other caregivers.
 Identify patients most likely to experience drug-related problems.
 Identify and prioritize a patient’s drug-related problems using input from
other health care providers and the patient.
 Develop and implement a pharmacy care plan by evaluating alternative
therapies, defining outcomes and developing a monitoring plan.
 Document direct patient activities in the patient’s health record in
accordance with health care organization and departmental policies and
procedures.
 Report and act on any significant adverse drug reactions.
2. The resident will demonstrate an understanding of the diseases of patients for
the purpose of identifying, preventing and resolving drug-related problems.
 Discuss, for the patients assigned, the following:
 Basic pathophysiology of the disease state in the patient with respect
to epidemiology, cause/etiology, clinical presentation, laboratory
indices affected, diagnostic criteria
3. The resident will demonstrate an understanding of the treatment of patients in
this population for the purpose of identifying, preventing and resolving drugrelated problems.
 Approach to therapeutic management, pharmacologic and nonpharmacologic
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Available pharmacologic measures and factors affecting the selection
of the optimal measure
 Incorporation of pharmacokinetic dosing and monitoring into the
therapeutic plan for the specific patient
 Pertinent monitoring parameters, including frequency, acceptable
endpoints and duration of monitoring, for both efficacy and toxicity
 Discuss the various therapeutic agents available for use in managing a
drug-related problem with respect to:
 Efficacy, including dosage regimens; toxicity; onset of action;
convenience/availability; drug interactions; cost/Pharmacare
coverage/Special Authority
4. The resident will integrate pharmacokinetic principles with patient-specific
parameters (eg. demographics, disease states, serum drug concentrations,
laboratory results, therapeutic endpoints) to perform appropriate
calculations/estimations to optimize drug therapy.
 Apply pharmacokinetic and pharmacodynamic principles and population
data to determine an individualized patient dosage regiment to resolve
and/or prevent a drug-related problem
 Assess the need for dosage adjustment based on patient clinical response
and appropriate therapeutic outcomes
 Perform appropriate calculations/estimations to determine an
individualized dosage regimen
 Communicate and document recommendations made to physicians and/or
nurses
5. The resident will develop the skills necessary to interview patients to assess
compliance and attainment of pharmacotherapeutic endpoints, need for
medication counseling, and counseling aids.
 Formulate a systematic approach to the preparation of the interview
 Demonstrate the ability/appropriate techniques to gather and observe
pertinent information during the interview
 Identify actual or potential drug-related problems using information from
the interview
 Assess compliance or the ability to comply with a medication regimen
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Formulate a plan to prevent or resolve any identified drug-related
problems
6. The resident will develop the skills necessary to effectively counsel patients on
medication use and condition management.
 Prepare verbal and/or written information
 Identify current knowledge of patient
 Provide information effectively to fill any gaps in knowledge
 Assess understanding by the patient of information provided
7. The resident will provide patients/care givers and health care professionals
with comprehensive but concise drug information.
 Independently utilize available drug information resources to research
pertinent literature necessary to resolve drug-related problems
 Effectively and efficiently communicate the response (written and/or
verbal)
 Answer the questions with appropriate terminology, conclusions,
recommendations and references
8. The resident will establish a relationship with the patient and work
cooperatively with other health care professionals in the provision of
pharmaceutical care.
 Communicate effectively and efficiently with patient on a daily basis
 Utilize care givers and other health care professionals for assistance in
identifying, preventing and resolving drug-related problems
 Consistently attend medical rounds, Kardex rounds or other assigned
activities
B. Practice Foundation Skills
Standard
The resident will develop the knowledge, skills and behaviours required to provide exemplary pharmaceutical care and function
independently as a competent health care professional.
Learning Objectives and Expected Outcomes
Narrative Commentary
1. Demonstrate ethical conduct in all pharmaceutical care activities.
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Identify ethical issues in practice
Practice a systematic approach to ethical problem solving (clarifying the
facts, clarifying the principles, determining the pharmacist’s duty)
 Act ethically in the conduct of all pharmaceutical care activities
2. The resident will establish a commitment to lifelong learning.
 Use a systematic, ongoing process to self-assess and meet learning
needs
 Demonstrate self-motivation by spending as much time as needed to learn
tasks
3.The resident will maintain active involvement in local, provincial, national and
international pharmacy organizations.
 Be actively involved in professional associations. CSHP membership is
mandatory and attendance at CSHP meetings and B.C. College of
Pharmacists meetings are particularly encouraged.
4.The resident will communicate clearly verbally and in writing.
 Organize all written and verbal communication in a logical manner
 Address all communication at the level appropriate for the audience
 Use correct grammar, punctuation, spelling, style, and formatting
conventions in the preparation of all written communications
 Speak clearly and distinctly
 Use public speaking skills to speak effectively in large and small groups
 Use listening skills consistently
 Use knowledge of the applicability of specific visual aids to enhance the
effectiveness of communications
 Use persuasive communication techniques effectively, when appropriate
 Communicate a positive image of pharmacy
 Use effective strategies for communicating with patients and care-givers
who are non-English
5.The resident will be able to solve practice problems efficiently.
 Apply principles of continuous quality improvement to daily activities
 Demonstrate consistent use of a systematic approach to problem-solving.
 Use consensus-building skills
 Resolve conflicts by apply principles of negotiating techniques
6.The resident will be able to work harmoniously with others in the health system.
 Apply necessary skills to work in a team environment
 Use a knowledge of interpersonal skills to effectively manage working
relationships
7.The resident will display empathy and compassion for patients and coworkers.
 Combine compassion with the practice of pharmacy
 Communicate with patients in an empathetic manner
 Be able to demonstrate an understanding of each patient’s medical and
social concerns
 Incorporate each patient’s wishes and concerns into the care plan to help
achieve the desired clinical outcomes
8.The resident will maintain confidentiality of patient information.
 Observe legal and ethical guidelines for safeguarding the confidentiality of
patient information.
9.The resident will contribute to the training of health care professionals and
support personnel.
 Use sound education techniques to teach pharmacy students, other health
care professionals, and support personnel.
10.The resident will arrange and store information in an organized manner.
 Adhere to an efficient system for organizing and storing information
relating to one’s practice.
11.The resident will provide and receive feedback in a positive manner.
 Deliver feedback to coworkers in professional and effective manner. Use
the IMPROVE or “sandwich technique” for delivering feedback
 Provide feedback in a timely manner, ensuring it is clear, descriptive, and
specific to the behaviour evaluated, with suggestions for improvement.
 Respond to feedback in a positive manner, incorporating and applying
feedback in new situations.
 Demonstrate self-evaluation that is balanced and insightful.
12.The resident will demonstrate principles of time management.
 Completes projects effectively and in a timely manner
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Demonstrates reliability and punctuality in completing all tasks.
Consistently attends and actively participates in meetings and other
assignments
Additional Learning Objectives
Narrative Commentary
At the completion of the formative evaluation with the resident, the following sections should be completed jointly by the preceptor and the
resident:
1. How will the resident change his learning during the remainder of the rotation time to facilitate completion of the learning objectives by the
resident?
2. How will the rotation be changed during the remainder of the rotation time to facilitate completion of the learning objectives by the resident?
Additional Comments:
Any issues with attitudinal or conduct performance?
(e.g. completion of assignments, proactive involvement in learning, punctuality, works independently when appropriate, communication,
organizational & time management skills)
Date: __________
Signed by Primary Preceptor
Date: ___________
Signed by Resident
Date: ___________
Signed by Residency Coordinator
Final Evaluation - Internal Medicine/Clinical Teaching Unit Rotation
Summative
Resident:
□ Preceptor Evaluation □ Self-Evaluation
Preceptor(s):
Rotation:
Dates of Rotation:
Assess the resident’s achievement of the objectives using the following scale. Explain any score of 2 or less in the Narrative section,
giving specific examples of unsatisfactory performance.
N/A—Not
applicable
Not
applicable to
this resident
or did not
observe
1—Unacceptable
2—Needs improvement
3—Acceptable
4—Above average
5--Exceptional
Cannot describe
process, procedure or
relevance of objective.
Consistently gives
inaccurate information.
Unable to perform task
or display attribute,
even with assistance
Significant gaps in
knowledge of process,
procedure or relevance of
objective. Sometimes
gives inaccurate
information. Requires
continual prompting to
give complete, accurate
response. Able to
perform task or attribute
only with support.
General knowledge of
process, procedure or
relevance of objective.
Provides complete and
accurate response with
minimal prompting.
Performs task or
displays attribute
independently.
Good knowledge of
process, procedure or
relevance of objective.
Provides complete and
accurate response with
minimal prompting.
Can perform task or
display attribute
independently.
Excellent, insightful
knowledge of process,
procedure or relevance
of objective. Information
always accurate and
complete without
prompting.
Independently performs
task or displays attribute
with a high degree of
skill.
Standard
The resident shall develop the knowledge and skills necessary to provide direct patient care using pharmaceutical care principles.
Learning Objectives and Expected Outcomes
1. The resident will demonstrate knowledge of the common disease states seen
in this patient population. Define disease state and risk factors, head to toe
Narrative Commentary
Score
pathophysiology and symptoms, basic understanding of diagnosis & general
management of the following:
 Angina [Chronic Stable (CAD) and Unstable (NSTEMI)]
 Myocardial Infarction (STEMI)
 Hypertension
 Dyslipidemia
 Diabetic Ketoacidosis
 Endocarditis
 Meningitis
 Pneumonia
 Osetomyelitis
 Atrial fibrillation/flutter (Acute and Chronic)
 Congestive Heart Failure (Acute Exacerbations and Chronic)
 Tubuculosis
 HIV
 Seizure disorder
2. The resident will demonstrate knowledge of the therapeutic alternatives
used in this patient population. Describe and compare traditional and
emerging therapeutic alternatives.
3. The resident will demonstrate knowledge of the pharmacotherapy used in
this patient population. Discuss: drug class, mechanism, effectiveness/ nondrug options, dose/ route/ frequency/ duration/ convenience/ economics,
onset/ peak/ duration /elimination (and factors affecting), head to toe side
effects/contraindications/interactions, monitoring (what, frequency, duration,
by whom).
 Beta blockers
 ACE Inh
 ARBs
 Statins
 Calcium Channel Blockers








Aspirin
Clopidogrel
Warfarin
Nicotine Replacement Therapy
Nitroglycerin
Various Antibiotics (including Gentamicin and Vancomycin)
Digoxin
Amiodarone
4. The resident will demonstrate knowledge of the complications seen in this
patient population. Define the complication and risk factors, head to toe
pathophysiology and symptoms, prevention, general management, monitoring
(what, frequency, duration, by whom).
 Swallowing difficulties
 Withdrawal symptoms
 Drug accumulations
 Fluid and Electrolyte disturbances
A. Direct Patient Care
Standard: The resident shall develop the knowledge and skills necessary to provide direct patient care using pharmaceutical care
principles.
.
Learning Objectives and Expected Outcomes
Narrative Commentary
Score
1. The resident will develop the skills necessary to identify, prevent and resolve
drug-related problems.
 Develop a patient database from the health records, the patient or family
members, and other caregivers.
 Identify patients most likely to experience drug-related problems.
 Identify and prioritize a patient’s drug-related problems using input from
other health care providers and the patient.
 Develop and implement a pharmacy care plan by evaluating alternative
therapies, defining outcomes and developing a monitoring plan.
Document direct patient activities in the patient’s health record in
accordance with health care organization and departmental policies and
procedures.
 Report and act on any significant adverse drug reactions.
2. The resident will demonstrate an understanding of the diseases of patients for
the purpose of identifying, preventing and resolving drug-related problems.
 Discuss, for the patients assigned, the following:
 Basic pathophysiology of the disease state in the patient with respect
to epidemiology, cause/etiology, clinical presentation, laboratory
indices affected, diagnostic criteria
3. The resident will demonstrate an understanding of the treatment of patients in
this population for the purpose of identifying, preventing and resolving drugrelated problems.
 Approach to therapeutic management, pharmacologic and nonpharmacologic
 Available pharmacologic measures and factors affecting the selection
of the optimal measure
 Incorporation of pharmacokinetic dosing and monitoring into the
therapeutic plan for the specific patient
 Pertinent monitoring parameters, including frequency, acceptable
endpoints and duration of monitoring, for both efficacy and toxicity
 Discuss the various therapeutic agents available for use in managing a
drug-related problem with respect to:
 Efficacy, including dosage regimens; toxicity; onset of action;
convenience/availability; drug interactions; cost/Pharmacare
coverage/Special Authority
4. The resident will integrate pharmacokinetic principles with patient-specific
parameters (eg. demographics, disease states, serum drug concentrations,
laboratory results, therapeutic endpoints) to perform appropriate
calculations/estimations to optimize drug therapy.
 Apply pharmacokinetic and pharmacodynamic principles and population
data to determine an individualized patient dosage regiment to resolve

and/or prevent a drug-related problem
Assess the need for dosage adjustment based on patient clinical response
and appropriate therapeutic outcomes
 Perform appropriate calculations/estimations to determine an
individualized dosage regimen
 Communicate and document recommendations made to physicians and/or
nurses
5. The resident will develop the skills necessary to interview patients to assess
compliance and attainment of pharmacotherapeutic endpoints, need for
medication counseling, and counseling aids.
 Formulate a systematic approach to the preparation of the interview
 Demonstrate the ability/appropriate techniques to gather and observe
pertinent information during the interview
 Identify actual or potential drug-related problems using information from
the interview
 Assess compliance or the ability to comply with a medication regimen
 Formulate a plan to prevent or resolve any identified drug-related
problems
6. The resident will develop the skills necessary to effectively counsel patients on
medication use and condition management.
 Prepare verbal and/or written information
 Identify current knowledge of patient
 Provide information effectively to fill any gaps in knowledge
 Assess understanding by the patient of information provided
7. The resident will provide patients/care givers and health care professionals
with comprehensive but concise drug information.
 Independently utilize available drug information resources to research
pertinent literature necessary to resolve drug-related problems
 Effectively and efficiently communicate the response (written and/or
verbal)
 Answer the questions with appropriate terminology, conclusions,
recommendations and references

8. The resident will establish a relationship with the patient and work
cooperatively with other health care professionals in the provision of
pharmaceutical care.
 Communicate effectively and efficiently with patient on a daily basis
 Utilize care givers and other health care professionals for assistance in
identifying, preventing and resolving drug-related problems
 Consistently attend medical rounds, Kardex rounds or other assigned
activities
B. Practice Foundation Skills
Standard
The resident will develop the knowledge, skills and behaviours required to provide exemplary pharmaceutical care and function
independently as a competent health care professional.
Learning Objectives and Expected Outcomes
Narrative Commentary
1. Demonstrate ethical conduct in all pharmaceutical care activities.
 Identify ethical issues in practice
 Practice a systematic approach to ethical problem solving (clarifying the
facts, clarifying the principles, determining the pharmacist’s duty)
 Act ethically in the conduct of all pharmaceutical care activities
2. The resident will establish a commitment to lifelong learning.
 Use a systematic, ongoing process to self-assess and meet learning
needs
 Demonstrate self-motivation by spending as much time as needed to learn
tasks
3.The resident will maintain active involvement in local, provincial, national and
international pharmacy organizations.
 Be actively involved in professional associations. CSHP membership is
mandatory and attendance at CSHP meetings and B.C. College of
Pharmacists meetings are particularly encouraged.
4.The resident will communicate clearly verbally and in writing.
 Organize all written and verbal communication in a logical manner
Score


Address all communication at the level appropriate for the audience
Use correct grammar, punctuation, spelling, style, and formatting
conventions in the preparation of all written communications
 Speak clearly and distinctly
 Use public speaking skills to speak effectively in large and small groups
 Use listening skills consistently
 Use knowledge of the applicability of specific visual aids to enhance the
effectiveness of communications
 Use persuasive communication techniques effectively, when appropriate
 Communicate a positive image of pharmacy
 Use effective strategies for communicating with patients and care-givers
who are non-English
5.The resident will be able to solve practice problems efficiently.
 Apply principles of continuous quality improvement to daily activities
 Demonstrate consistent use of a systematic approach to problem-solving.
 Use consensus-building skills
 Resolve conflicts by apply principles of negotiating techniques
6.The resident will be able to work harmoniously with others in the health system.
 Apply necessary skills to work in a team environment
 Use a knowledge of interpersonal skills to effectively manage working
relationships
7.The resident will display empathy and compassion for patients and coworkers.
 Combine compassion with the practice of pharmacy
 Communicate with patients in an empathetic manner
 Be able to demonstrate an understanding of each patient’s medical and
social concerns
 Incorporate each patient’s wishes and concerns into the care plan to help
achieve the desired clinical outcomes
8.The resident will maintain confidentiality of patient information.
 Observe legal and ethical guidelines for safeguarding the confidentiality of
patient information.
9.The resident will contribute to the training of health care professionals and
support personnel.
 Use sound education techniques to teach pharmacy students, other health
care professionals, and support personnel.
10.The resident will arrange and store information in an organized manner.
 Adhere to an efficient system for organizing and storing information
relating to one’s practice.
11.The resident will provide and receive feedback in a positive manner.
 Deliver feedback to coworkers in professional and effective manner. Use
the IMPROVE or “sandwich technique” for delivering feedback
 Provide feedback in a timely manner, ensuring it is clear, descriptive, and
specific to the behaviour evaluated, with suggestions for improvement.
 Respond to feedback in a positive manner, incorporating and applying
feedback in new situations.
 Demonstrate self-evaluation that is balanced and insightful.
12.The resident will demonstrate principles of time management.
 Completes projects effectively and in a timely manner
 Demonstrates reliability and punctuality in completing all tasks.
 Consistently attends and actively participates in meetings and other
assignments
Additional Learning Objectives
Narrative Commentary
Score
Strengths/Weaknesses/Suggestions for Improvement:
Personal Learning Plan (Resident):
Any issues with attitudinal or conduct performance?
(e.g. completion of assignments, proactive involvement in learning, punctuality, works independently when appropriate, communication,
organizational & time management skills)
PASS/ FAIL:
Date: __________
Signed by Primary Preceptor
Date: ___________
Signed by Resident
Date: ___________
Signed by Residency Coordinator