Knowledge Assessment 4: Clinical Decision Making

Pharmacist's Patient Care Process

Collect -> Assess -> Plan -> Implement -> Follow Up: Monitor and Evaluate

Pharmacist's Patient Care Process: Collect

conduct a comprehensive review of medications, associated health and social history by previewing available electronic health data and patient interview

corresponds to Subjective and Objective portions of Clinical Documentation

Pharmacist's Patient Care Process: Assess

formulate a medication therapy problem list and prioritize medication therapy problems by considering indication, efficacy, safety, and adherence

reflects medication list that is accurate

accurate problem list in order of priority

connects signs and symptoms with patient presentation and issue

identifies whether patient is at treatment goals

considers risk factors as part of assessment

includes interpretation of patient logs or diary

In the pharmacist's patient care process, assess reflects....

medication list that is accurate

In the pharmacist's patient care process, assess has an accurate...

problem list in order of priority

In the pharmacist's patient care process, assess connects....

signs and symptoms with patient presentation and issue

In the pharmacist's patient care process, assess identifies....

whether patient is at treatment goals

In the pharmacist's patient care process, assess considers....

risk factors as part of assessment

In the pharmacist's patient care process, assess includes....

interpretation of patient logs or diary

Pharmacist's Patient Care Process: Plan

develop an individualized evidence-based plan in collaboration with other healthcare professionals and patient with/or caregiver that is evidence based and affordable

What does the 'Pharmacist's Patient Care Process' plan provide?

justification that links assessment to the plan through disease state guidelines

optimizes medication focused treatment based on renal, liver function

considers drug interactions

evaluates social determinants of health

What does the 'Pharmacist's Patient Care Process' plan include?

comprehensive evidence-informed plan that addresses disease state management

differentiates actions to take for today versus future actions

considers pharmacological and non-pharmacological therapies

Pharmacist's Patient Care Process: Implementation

in collaboration with the patient and/or caregiver and other members of the healthcare team

a medication order with full sig is entered into the electronic health record

- medication order within the note includes "stop" and "start" criteria

the patient receives education which includes therapy plan with medication name and directions, indication and mechanism, use and storage, potential for adverse effects

instructions on when and how to seek additional care

When the patient receives education about their plan implementation, what does this include?

therapy plan with medication name and directions, indication and mechanism, use and storage, potential for adverse effects

Example of Implementation

Patient to start rosuvastatin 20 mg tablet once daily by mouth

Discussed PREVENT risk score with patient who verbalizes understanding of ASCVD risk. Patient to take rosuvastatin 10 mg tablet by mouth each evening to decrease ASCVD risk. Provided patient education of how this medication lowers LDL cholesterol to decrease ASCVD risk. Patient to keep medication in closed cabinet. Discussed potential of adverse effects including myopathy, increase in HbA1c.

Patient will observe for cola-colored urine and muscle pain or weakness and will contact clinic with first symptoms

Pharmacist's Patient Care Process: Follow-Up, Monitoring, Evaluation

the date and time of follow-up and the individual who will follow-up with the patient is identified

a discussion of goals, time of achievement, and potential strategies is identified

- idenfies measures of efficacy

- identifies measures of safety

summarize visit with patient and consider teach-back

Example of Follow-Up, Monitoring, and Evaluation

Patient is return to clinic in 3 months for follow-up lipid profile with Clinical Pharmacist to determine benefits of new therapy.

Anticipate rosuvastatin to lower LDL by around 50% to achieve LDL goal of < 70 mg/dl.

Will monitor for any adverse effects

including symptoms of myopathy or cola colored urine. Patient is to report any new medications prescribed to clinic.

Patient scheduled for follow-up with NP in 6 months

The Health Care Team and Clinical Decision Making

patient is at the center

Clinical Knowledge (Preparation): Defined

recognizes disease patterns

perceives lab testing necessary to gather relevant information

discerns mechanism of action for medications that address the patient's problems

identifies clinical facts to categorize problems

Clinical Knowledge (Preparation): Applied

understands pathophysiology of disease state presentation

relates lifestyle and social determinants of health to disease

recognizes presentation of disease in a patient

Clinical Reasoning (Collect and Assess): Defined

asks the questions appropriate for the patient at hand

problems are defined and solutions are generated

Clinical Reasoning (Collect and Assess): Applied

chart review and patient interview conducted

potential symptoms of disease identified

corresponding labs are considered

physical exam performed

create a working diagnosis

Clinical Reasoning Checklist #1

all clinical reasoning has a focused purpose with objectives that are realistic

Clinical Reasoning Checklist #2

all clinical reasoning is an attempt to figure something out, settle a question, or solve a problem which may necessitate dividing the question up and applying clinical judgement

Clinical Reasoning Checklist #3

all clinical reasoning is based on assumptions which can influence your point of view and should be open to scrutiny

Clinical Reasoning Checklist #4

all clinical reasoning is done from some point of view which can have strengths and weaknesses

Clinical Reasoning Checklist #5

all clinical reasoning is based on data, information, and evidence which may or may not be relevant to the clinical issue at hand

Clinical Reasoning Checklist #6

all clinical reasoning is expressed through, and shaped by, concepts and theories

Clinical Reasoning Checklist #7

all clinical reasoning contains inferences or interpretations by which we draw conclusions and give meaning to data

the inferences or interpretations should be consistent with each other, relevant, and reasonable

Clinical Reasoning Checklist #8

all clinical reasoning leads somewhere, that it, has implications and consequences

Critical Thinking (Plan): Defined

interpretation

analysis

evaluation

inference

explanation

self-regulation

sum of attitudes, skills, and knowledge of critical thinking

Critical Thinking (Plan): Applied

problem identification and recognition of potential solutions (Generate)

define problem boundaries with working hypothesis (Conceptualize)

critically weigh alternatives (Optimize)

applies analytical systems thinking

Systems Thinking: System 1 (Non-Analytical)

fast, intuitive

learned by repetition

non-analytical

initial impression

error prone

Systems Thinking: System 2 (Analytical)

slow, deliberate

cognitively demanding

analytical, logical

rational

override to system 1

Clinical Decision Making: Defined

uses clinical and biomedical knowledge to problem solve

determines probabilities of different outcomes

considers risk and benefit for patient treatment decisions

plan is realized

action is taken

Clinical Decision Making: Applied

reviews patient information obtained

considers best evidence for treatment

decides impact of various pharmacological, nonpharmacological therapies

discusses options with patient and healthcare team

Clinical Decision Making (PCPP): Patient Particulars

subjective information:

- patient findings

objective information:

- existing medications

- lab results

- diagnostic tools

Clinical Decision Making (PCPP): Evidence Based

Guideline Directed Medical Therapy

patient specific

decision support tools

team aligned

Clinical Decision Making (PCPP): Patient Preference

lifestyle interventions

pharmacologic therapy

patient education

Risk Factors for Cognitive Error: Methods to Address Bias - Knowledge, Training, and Experience

initially identifying "illness scripts"

consider epidemiology

access guidelines or diagnostic checklists

ask "what does not fit?"

work with a team

reassess therapy response

Risk Factors for Cognitive Error: Overconfidence

recent encounter of similar situation

generalizations

Risk Factors for Cognitive Error: Physical Limitations

workload, distractions, team

Risk Factors for Cognitive Error: Bias

personal viewpoints

Cognitive Error: Bias - Implicit Bias

attitudes and perceptions that include stereotypes and attitudes

Cognitive Error: Bias - Methods to Address

1. Perspective-taking: empathizing with others

2. Emotional regulating: keeping one's emotions in check

3. Partnership creation: patients join team in decision making

4. Culture perspective: understanding the patient's culture

5. Bias understanding: realizing that there is bias

6. Individuating: treating each patient individually

Cognitive Error: Heuristics

mental shortcuts relying on pattern recognition and prior experiences rather than rigor from evidence

Cognitive Error: Intellectual Standards

clarity

relevance and significance

objectivity and fairness

accuracy and precision

depth and breadth

logicalness