patient assessment and clinical interviewing 1257564079 phpapp01

8/11/2019 Patient Assessment and Clinical Interviewing 1257564079 Phpapp01

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Patient Assessment and Clinical

Interviewing


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Common Communication Mistakes

Health Care Practitioners MakeFrom: Lessons from medicine and nursing for pharmacist -

patient communication, Am Jour of Health SystemPharmacists, Vol. 53, June 1996, pages 1306-14.


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Common Mistakes:1. Failure to greet patients, tell them who you are and

the purpose of your interaction with them.2. Failure to find out what is bothering the patient

worries, concerns, issues how the patient feelsabout their condition.3. Accepting vague information too easily and not

probing to find out more specifics.

4. Failure to verify that what you thought you heard,was what the patient really meant

5. Failure to encourage patient questions.6. Failure to be responsive to patient questions.


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Common Mistakes:7. Not paying attention to the verbal and NON-verbal

communication messages sent by patients.8. Avoiding information that is personal.

9. Using too many closed ended questions.10. Allowing interruptions.11. Drawing conclusions too soon.

12. Failure to provide appropriate information in theform of counseling.

13. Not understanding the patients viewpoint.

14. Poor reassurance.


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Cultural Issues

Home Remedies?


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Sample questions to explorecultural beliefs about health,

illness and treatment: What do you think caused your problem?

When /why do you think it started when it did? How bad is your sickness? What do you think should be done to get rid of

this sickness? How have you treated this illness? What worries you about this sickness? Do you think your treatment will help?


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Recommendations to Enhance

Cultural Sensitivity First, all your communication skills from

the tool box still apply.

Recognize that cultural diversity exists. Accept that new to you can be stressful to

you.

Know your own culturally derived preferences and values. Rely on your rapport!


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Cultural Sensitivity Listen and attend to verbal and non-verbal

cues that could provide information to you.

Remember that YOU might be facingsomething completely new to your beliefsystem.

Develop a genuine acceptance, respect andtolerance for your patients cultural values.


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Cultural Sensitivity Acknowledge that you dont know everything and

ask your patients to explain the things you dontunderstand.

Stephen Covey: seek first to understand. Do not label or judge customs, norms, or habits

your patients present.

Approach cross cultural situations with awillingness to explore your patients world. Meet and develop rapport with members of other

cultures.!


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When will I need patientassessment or clinicalinterviewing skills?


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The Pharmacy Care ProcessCollect and use

patient information

Identify patients drugrelated problems

Develop solutionsto these problems

Select and recommendtherapies

Follow up to assess patient outcomes


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When will I need patientassessment or clinicalinterviewing skills?

Patient counseling

Examining patients Making OTC recommendations Many other situations:

hospitals, long term care Ambulatory clinics such as anticoagulation, other

disease management efforts, HTN, diabetes, asthma, flushot clinics, collaborative practices with physicians andother providers


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We want to differentiateassessment and interviewing

from counseling but the sameskills apply.

One of the primary differences isdocumentation.


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Questions asked in the background of the pharmacists

mind while conducting patientassessment activities:


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Patient Assessment Questions:

Are any of the patients complaints orabnormal objective/physical findings related

to drug therapy? What are some other possible causes of the

patients complaints / symptoms?

Are each of this patients medicationsappropriately prescribed?


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Is each medication the best one for this patient to be taking? Safest, most effective?

Is this the right dose given the patientspecific information (severity, size, gender,etc.)

Is the patient having any apparent drugrelated side effects?


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Are any possible drug interactions present? Is this patient able to follow this drug

regimen? Does the patient know how to use this

medication correctly?

Is additional medication needed to resolvethe patients complaint / symptom?


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Documentation

Provides a permanent record of patientinformation.

Provides a record and evidence of pharmacy care provided.

Communicates to other practitioners what youhave done.

Provides a legal record of what you have done. Provides documentation for billing purposes.


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Documentation

Legally, if it isnt documented it wasntdone

From a billing perspective, each CPTEvaluation and Management Code requirescertain information be recorded in the chart.

99211; very basic, 5 minutes or less.Requires only 1 vital, date, provider,

problem addressed.


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Pharmacy Consultant NoteAthens Primary Care Pharmacy Clinic

Patient Name: Sample PatientConsult Date: 10/03

Medication(Name/Strength/Dose/Route/Frequency)

Indication Medication(Name/Strength/Dose/Route/Frequency)

Indication

Nexium 40mg 1 PO QD GERD Tramadol 50mg 3 PO QAM Pain

Amaryl 2mg 1 PO QD Type 2 diabetes Promethazine 25mg PRN Nausea

Diphenoxyalate/Atropine PRN Diarrhea Ketoprofen 20% in Lipoderm Gel topical Knee stiffness

Tricor 160mg 1 PO QHS Cholesterol HCTZ 12.5mg 1 PO QAM HTNAltace 10mg 1 PO BID HTN

Potential Problem Recommendation Recommendation For MDAccepted Y/N (if no,

explain) Blood pressure fluctuates greatly from day to day Add another BP med, possibly a CCB after complete evaluation

Y / N

Diabetes not well controlled eed to check A 1Cs; pt. needs to check blood sugar, record it formonitoring; add 2 nd drug if appropriate Y / N

Amaryl has no refills Refill if appropriateY / N

Is cholesterol being controlled? Check lipidsY / N

Pharmacy Student: J.C. Faculty Advisor: Dr. Matt Perri, Dr. Jennifer Phillips


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The SOAP Note

Subjective complaints, symptoms, recenthistory, past medical history, medication history,allergies, social and family history, review ofsystems.

Objective vital signs, physical findings fromexamination, labs tests, blood levels of drugs,medication profile.

Assessment critical thinking and analysis of the problem.

Plan actions to be taken.


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Problem Oriented Note

Generate a list of patient problems and provide a SOAP note for each problem (or

closely related problems.) Be consistent. When no drug therapy problems are noted,

state this.


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General Types of Data to Collect

in a Clinical Interview Name, address, phone, fax, email, etc. Height and weight (physical assessment).

Primary physician, specialists, dentists, addressesand phones if possible.

Insurance information (copy of card if possible).

Rx and OTC medication lists. Herbal supplements, vitamins, and any other

substances used.


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in a Clinical Interview Medical problem list, including date

diagnosed, surgeries, hospitalizations, etc.

Pregnancy, lactation. Alcohol and tobacco use. Labs, if available. Special monitoring that the patient

performs.


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in a Clinical Interview Possible compliance barriers. Any patient concerns or questions Name and title of person collecting the

information.


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Specific Data Needed:

Chief Complaint A brief statement of why the patient is seeking

care. 1-2 primary symptoms with their duration. Recorded in the patients own words.

Remember, patients may not always have aCC: they may present with a problem they donot know is drug related.


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History of present illness Timing, onset, duration and frequency of Sx.

Location Quality (sharp, dull, ache, red blood, tarry stools) Quantity or severity of Sx (mild, moderate, severe) Setting: when do the Sx occur?

Aggravating or relieving factors Associated symptoms (other Sx that occur in

conjunction with the primary Sx)


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Past Medical History List of past problems, related or not to the CC

Family History Presence or absence of illness in the immediate

family (living or dead, illnesses F 67 (CVA)

Social History ETOH, tobacco, exercise, etc.


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Review of Systems General health

Skin, hair and nails Eyes, ears, nose and throat Head and neck Respiratory system Cardiovascular Gastrointestinal


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Review of Systems Hepatic / Renal

Musculoskeletal Nervous system Mental status Endocrine system (diabetes and thyroid) Male reproductive system Female reproductive system

patient assessment and clinical interviewing 1257564079 phpapp01

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