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The Patient Care Process Assessment: Part I Information Gathering Lalitha Raman-Wilms, PharmD, FCSHP Associate Professor Leslie Dan Faculty of Pharmacy University of Toronto Session II • Part I: Assessment: Information Gathering • Part II Assessment: Pharmacotherapy Work-up • Part III Care Plan & Follow-up Evaluation Learning Objectives: Part I • Describe how patients’ medication taking experience relates to their drug-related needs • List the specific types of information to be gathered in order to assess patients’ drug therapy • Describe how patients’ Current Medication Record should be documented • List the specific types of information related to the past medication history which should be considered in the management of current conditions • Describe what information should be included in a Current Review of Systems Pharmaceutical Care Practice: How does a pharmacist provide this care? • With a patient-centered approach: patient’s drug-related needs drive practice – START WITH THE PATIENT • Use a consistent process in providing this care – called the PATIENT CARE PROCESS • Identify and resolve patients’ DRUG THERAPY PROBLEMS • DOCUMENT this care in an efficient & usable manner • Work with the patient’s HEALTH CARE TEAM Patient Care 1 Process • Assessment Of patient’s drug-related needs Identify problems related to drug therapy Establish a trusting relationship • Care Plan Address identified drug therapy problems and work to achieving goals for each condition • Follow-up evaluation Ensure goals are met; no new problems related to drug therapy 1Pharmaceutical Care Practice, 2004, Cipolle et al Continuous follow-up ASSESSMENT Assessment of Drug Therapy1 Activities Responsibilities Meet the patient Establish the therapeutic relationship i.e. develop an effective relationship with the patient Elicit relevant information from patient (& the patient’s chart & other health care professionals) Determine who pt is, reason for encounter, demographics, medication experience, and other clinical information i.e. GATHER THE RELEVANT INFORMATION Make rational drug therapy decisions using the Pharmacotherapy Workup Are patient’s drug-related needs being met? Identify drug therapy problems 1Pharmaceutical Care Practice 2004, Cipolle, Strand, Morley, The Patient Care Process, page 11. Patient-Pharmacist Relationship • Based on: Mutual respect, Trust, Open Communication, Cooperation, Mutual Decision Making – Essential clinical skills: inquiry, listening, and observational skills – Effective use pharmacotherapeutic knowledge – Practitioner must collect information and make clinical decisions, in partnership with the patient – Work collaboratively with patient’s other health care providers to optimize care Assessment of Drug Therapy1 Activities Meet the patient Responsibilities Establish the therapeutic relationship i.e. develop a trusting relationship with the patient Elicit relevant information from Determine who pt is, reason for patient encounter, demographics, medication experience, and other clinical information i.e. GATHER THE RELEVANT INFORMATION Make rational drug therapy decisions using the Pharmacotherapy Workup 1Pharmaceutical Are patient’s drug-related needs being met? Identify drug therapy problems Care Practice 2004, Cipolle, Strand, Morley, The Patient Care Process, page 11. Patient’s medication experience • Their general attitude toward medications; their understanding and expectations of their medications – e.g. ‘natural remedies like herbs are safer; I don’t like medications’ – Consider patient’s cultural, health care beliefs • ‘Patient concerns – ‘This medication has a lot of side effects and I am not sure I want to take it; maybe I can take it only when I need it’ What is your understanding of your medications? What do you expect from your medications? What are your concerns about your medications? Responses • Why are they taking the medication? – Relates to the need for drug therapy: • Is the drug indicated? • What are their expectations? – What they think the drug will do for them • Is the drug effective? • What are their concerns? – What are they concerned the drug may do? • Is the drug safe? All of the above determine if the individual will take the drug! Responses • Why are they taking the medication? – Relates to the need for drug therapy: • Is the drug indicated? INDICATION • What were their expectations? – What they think the drug will do for them • Is the drug effective? EFFECTIVENESS • What were their concerns? – What are they concerned the drug may do? • Is the drug safe? SAFETY All of the above determine if the individual will take the drug! Drug-related needs • Individual’s understanding of why they are taking their medications • Their expectations related to their medications • Their concerns related to their medications TRANSLATE INTO PATIENT’S DRUG-RELATED NEEDS Patient’s drug-related needs • Understanding of their medications • INDICATION • Expectations of medications • EFFECTIVENESS • Concerns related to their medications • SAFETY • Are they able to take it as appropriate? • COMPLIANCE / ADHERENCE Information Gathering: • Reason for the encounter / main complaint • Patient Demographics (age,ht, wt, living situation) • Patient’s understanding, expectations & concerns • Current medications & conditions • Past medications & conditions (allergies, immunizations, what worked well, what did not and why) • Medication-related review of systems Information Gathering: Patient, Disease and Drug Information Drug Therapy Problems Prioritize 1. Reason for the encounter / main complaint 2. Patient Demographics 3. Patient’s understanding, expectations & concerns 4. Current medications & conditions 5. Past medications & conditions (allergies, immunizations, what worked well, what did not and why) 6. Medication-related review of systems 4. Current Medication Record • All current medications used by the patient – This includes prescribed drugs, OTC products, herbals and vitamins which may be self-selected by the patient and topical products • Information should include generic drug name, dose, frequency, duration if appropriate • Consider how best to organize this information to enable clinical decision on its effectiveness & safety The Current Medication Record • INDICATION – the reason the patient is taking the medication • DRUG PRODUCT – includes the drug name, the dosage strength • DOSAGE REGIMEN – the dose, the frequency of administration, the route • START DATE – when patient started to take the medication • RESPONSE – includes both positive effects and negative effects of drug therapy The Current Medication Record Effectiveness Indication Drug product Dosage regimen Outcomes Safety Figure 7-1 Organization of Current Medication Record Indication Hypertension Drug Dosage Product Regimen 25 mg po chlorothiazide qam Hydro- Outcome BP 135/85 4. Organization of Current Medication Record Indication Drug Product Dosage Regimen hypertension Hydrochloro- 25 mg po thiazide qam Start Date Jan 3, 2012 Outcomes: Effectiveness / Safety BP: 135/85 No reported side effects 5. Past Medication History • Understanding of effectiveness and safety concerns from past use • Allergies, Adverse Drug Reactions, Immunizations, special needs (can’t swallow large pills), use of caffeine, tobacco, etc., what worked & what did not work previously and why • Usually discussed during the patient’s first encounter with the pharmacist 6. Information GatheringReview of Systems Review of Systems: • Vital signs: BP, Temp, HR, RR • Head/Neurological: Psychological • EENT • CV • Pulmonary • Fluid/Electrolyte • • • • • • Hepatic Endocrine Hematology Gastrointestinal urology/reproductive Musculoskeletal Skin Information Gathering: Patient, Disease and Drug Information Drug Therapy Problems Prioritize 1. Reason for the encounter / main complaint 2. Patient Demographics 3. Patient’s understanding, expectations & concerns 4. Current medications & conditions 5. Past medications & conditions (allergies, immunizations, what worked well, what did not and why) 6. Medication-related review of systems Information Gathering Only collect information which is needed now to assess the patient’s drug-related needs and identify drug therapy problems. The main area to focus on is the patient’s primary problems or concerns. Learning Objectives: Part I • Describe how patients’ medication taking experience relates to their drug-related needs • List the specific types of information to be gathered in order to assess patients’ drug therapy • Describe how patients’ Current Medication Record should be documented • List the specific types of information related to the past medication history of patients which should be considered in the management of current conditions • Describe what information should be included in a Current Review of Systems