Final Exam 519

Why is PROPER documentation important?

• enhance our ability evaluate care, plan tx, monitor care over time

• ensure effective communication and continuity of care among members of the health care team

• improve quality of care

types of documentation

• SOAP notes

• FARM notes

• pharmacy consult notes

  • anticoagulation consult - warfarin dosing

  • pharmacokinetic consult - abx dosing

SOAP note = progress note

• Subjective

• Objective

• Assessment

• Plan

Most common method for documenting pt encounters systematically

1. SUBJECTIVE DATA

• data reported from pt/caregiver

• second-hand info

• include:

  • CC

  • HPI

  • PMH

  • medications and immunization

  • allergies

  • Family hx

  • social hx

  • ROS

ex:

• pt says their sx are headache, CP…

• pt says their BP is 130/90

2. OBJECTIVE DATA

• facts, physical findings

• data that is measurable and tangible

• include:

  • Physical exam

  • VS

  • Labs

  • calculations

  • dx tests

ex: lab work, imaging, weight, VS

where do we get pt info?

• fr. pts and caregivers - subjective info

• fr. medical/pharmacy record - objective info

• fr. other health care professionals - objective info

chief complaint = CC

• SUBJECTIVE data

• brief 1-2 lines of pt’s main sx or concern

• why is the pt here

history of present illness = HPI

• SUBJECTIVE data

• your narrative of pt’s CC

• “reports” , “denies” , “states”

past medical history = PMH

• SUBJECTIVE data

• reported medical conditions and dx

medications and immunizations

• SUBJECTIVE data but can also be found under OBJECTIVE

  • depends on where we get the info from (from pts vs. EMR)

• including:

  • rx

  • OTC

  • herbals

  • including name, dose, route, frequency

allergies

• SUBJECTIVE data

• including:

  • medication allergies

  • food allergies

  • latex, adhesive…

family history = FH or FHx

• SUBJECTIVE data

• including medical hx of family members

  • deceased or alive

  • if not pertinent => noncontributory

social history = SH or SHx

• SUBJECTIVE data

• including:

  • diet, physical activity

  • tobacco, alcohol, drug use

  • occupation

  • living situation

  • support system

review of system = ROS

• SUBJECTIVE data

• including:

  • pt-reported answers to provided questionnaire

  • organized by organ system

physical exam

• OBJECTIVE data

• physical findings by organ system

VS

• OBJECTIVE data

• including:

  • temp

  • BP

  • HR

  • RR

  • SpO2

labs

• OBJECTIVE data

• including all the blood work

Calculations

• OBJECTIVE data

• including:

  • BMI

  • creatinine clearance (CrCI)

  • 10-year ASCVD risk score

dx tests

• OBJECTIVE data

• include:

  • echo

  • EKG

  • PFT

  • CXR

3. Assessment

• the WHY

• provide rationale for our PLAN

• include:

  • Prioritized problem list

  • Goals of therapy (short term vs. long term; disease-oriented vs. patient-oriented evidence)

  • Classifying problems (which stage? controlled or uncontrolled?)

  • Assessment of current therapy (AESA)

  • Changes to Medications (changes to current therapy, need to continue/discontinue/initiate regimen?)

  • Assess non-pharm/lifestyle factors (diet, exercise…)

  • Preventive health (immunization needs?)

4. Plan

• the WHAT - what should be done

• plan + implement + monitoring + f/u

• state recs clearly + concisely

• include:

  • pharmacologic recs (continue, increase, decrease, initiate, discontinue)

  • monitoring parameters

    • therapeutic - how do we know a med is working?

    • toxic - how do we know a med is causing harm?

  • non-pharm recs (lifestyle)

  • pt edu and pt counseling

  • f/u (when, what, who)

• Continue, Initiate, Start, Discontinue, Increase, Decrease

adult immunization practice

• need to assess immunization status at every visit (age, health conditions, lifestyle, travel, occupation)

• recommend vaccines

• administer vaccines or refer to provider

• document the vaccines

live vaccines

ONLY THESE

• Dengue (DEN4CYD)

• influenza (only LAIV4)

• MMR

• Rotavirus (RV1 and RV5)

• Varicella (VAR)

bacterial vaccines

ONLY THESE

• diphtheria, tetanus

  • with acellular pertussis (DTaP, Tdap)

  • without acellular pertussis (Td

• Haemophilus influenza type b (Hib)

• Meningococcal

  • MenACWY (D, CRM, TT)

  • MenB (4C, FHbp)

• Pneumococcal

  • PCV13

  • PCV15

  • PCV20

  • PPSV23

primary prevention

action taken to prevent the development of a disease/event

ex: pregnancy prevention

secondary prevention

action taken to reduce the recurrence of a disease/event that has already occurred

ex: screening pregnant women on depression risks

tertiary prevention

action taken to soften the impact of an ongoing disease/event that has lasting effects

ex: treat pregnant women with depression; treat babies?

HTN

• 2017 ACC/AHA guidelines - systolic >= 130mmHg or diastolic >= 80

• screening criteria:

  • age 18 and up

  • age 18-39 + normal BP + no risk factors —> SCREEN EVERY 3-5 YRS

  • age 40 and up OR with risk factors —> SCREEN ANNUALLY

• screening: 2 or more readings from different days >= 130/80

• risk factors

  • age

  • African Ame

  • overweight or obese

  • pregnancy

  • smoking

  • poor diet

  • sedentary lifestyle

diabetes

• Criteria

  • Testing for adults with OVERWEIGHT or OBESE and

    • 1st degree relative with DM

    • high risk race/ethnicity

    • history of CVD

    • HTN

    • low HDL and/or high trig

    • women with polycystic ovary syndrome

    • physical inactivity

    • other clinical conditions a/w insulin

  • Pre-DM —> TEST ANNUALLY

  • Women with Gestational DM —> LIFELONG TESTING AT LEAST EVERY 3 YRS

  • >= 45 —> TEST ANNUALLY

  • HIV pts —> TEST ANNUALLY

• DX screening:

  • fasting sugar >= 126 mg/dL (7 mmol/L)

  • 2-h sugar >= 200 mg/dL (11mmol/L) during oral glucose tolerance test (OGTT)

    • dx requires 2 abn tests from same samples or in 2 separate samples

  • A1C >= 6.5% (48 mmol/mol)

fasting blood glucose = FBG

blood glucose levels after no eating/drinking for at least 8 hours

post prandial glucose = PPG

blood glucose levels after a meal, taken 2 hours after eating

hyperglycemia sx

• polyuria

• polydipsia = extremely thirsty

• polyphagia = extremely hungry

ASCVD risk factors

• age

• race

• total + HDL levels

• LDL

• sBP

• smoking status

why do pharmacists need to know about nutritional assessment?

• so they can refer

• malnutrition and over nutrition are a/w negative clinical outcomes and increased morbidity/mortality

• diet changes = 1st line therapy for dz

• some drugs can alter nutrients levels and/or absorption in body

nutritional assessment

1) Anthropometric measurements

2) Biochemical and immune function studies

3) Clinical - specific nutrient deficiencies/clinical eval

4) Dietary - assessment of nutrient requirements

1) anthropometric measurements

• physical measurement of size, weight, proportions of human body

  a) BMI

  b) Waist circumference = WC

  c) body composition

a) BMI (Anthropometric measurements)

• kg/m²

• pros: easy to obtain, inexpensive

• cons: doesn’t show body composition or location of fat

b) waist circumference = WC (Anthropometric measurements)

• measure around your middle (above hips)

• pros: identify central/abdominal obesity; easy to get

• cons:

  • doesn’t determine visceral vs. subcutaneous fat (visceral fat = fat around internal organs; subcutaneous fat = fat just below skin)

  • doesn’t describe body composition

c) body composition (anthropometric measurements)

• Dual Energy Xray Absorptiometry (DXA/DEXA) for bone density - GOLD STANDARD

• Bioelectrical analysis

  • use conduction of an alternating electrical current that passes thru tissues containing a lot of water and electrolytes (like blood and muscles)

  • does not pass as easily thru fat tissues, air, bone

  • ex: InBody scan (more accessible compared to DEXA scan but less accurate; check body fat vs. muscle of body - like at a fitness)

• muscle mass is a predictor of longevity

  • b/c if we lose muscles = we fall

  • muscle is more metabolically active —> more muscles = the more it affects our metabolism

• pros: most accurate, most detailed

• cons: more expensive, not as accessible; DEXA scan has some radiation exposure

2) Biochemical and Immune Function Studies (lab)

• visceral protein concentrations

  • serum proteins a/w nutrition risk (Albumin, Transferrin, Prealbumin or transthyretin)

  • can tell us about malnutrition, deficiency, dehydration, infxn…

• immune function

  • nutrition status can affect immune function

  • total lymphocyte count and delayed cutaneous hypersensitivity rxns

—> any of these tests can tell malnutrition vs. over nutrition —> help create a clinical pic

3) Clinical: Specific Nutrient Deficiencies/Clinical Eval

• in hospital or dr office

• assessment of trace element, vit, essential fatty acid deficiencies

  • some vits from diet (zinc, copper, manganese, selenium, iodine, iron… —> deficiencies of these trace elements = clinical syndromes)

  • multiple vit deficiencies occur more commonly with malnutrition

  • essential fatty acid deficiency is rare, but can occur

• pt clinical history

  • look at weight loss? GI sx? oral health? inability to chew/swallow? chronic/acute disease? psychiatric illness? loss of muscle mass?

• physical exam

  • evaluate clinical signs and sx of nutritional deficiencies of vits and minerals

4) Dietary: Assessment of Nutrient Requirements

• assess current food intake, diet hx, medications, supplements

  • consider dietary preferences, cultural and religious habits, food allergies, fluid intake, alcohol intake, age, physical activity

• energy requirements and comparison btw food intake & energy expenditure —> can tell nutrition status

  • TDEE = total daily energy expenditure = most of it is made up of basal metabolic rate (BMR) = how much energy is needed to survive at rest

    • know relatives number only!!!

      a) RMR = resting metabolic rate or BMR = basal metabolic rate = 70% of TDEE (use predictive equations or measure)

      b) Exercise activity thermogenesis = EAT = 5% of TDEE (ex: exercise, HIIT)

      c) Thermic effect of food = TEF = 10% of TDEE (how much calories it takes to digest that food; depends on macronutrient content of food); proteins > carbs > dietary fat has the highest TEF

      d) non-resting energy expenditure = NEAT = 15% of TDEE = daily movement if not sleeping (ex: walk to car, walk upstairs, work)

  • REE = resting energy expenditure

  • NREE = non-resting energy expenditure

—> keep a food journal for assessment of macronutrients (fats, carbs, proteins) and micronutrients (vits, trace elements)

• fluid intake - daily adult requirement (30-40mL/kg)

• drug-nutrient interactions

  • drug therapy can change serum concentrations of vits, minerals, electrolytes

  • some drug delivery vehicles contain nutrients (ex: most IV therapies include dextrose or sodium)

histamine-2 antagonists

• Pepcid, Zantac

• these drugs reduce acid —> can’t absorb vit B12 well —> vit B12 malabsorption

abx

cause vit K deficiency

aspirin

cause folic acid deficiency

increase vit C excretion

cathartics = laxatives

cause increased requirements for vit D, C, B6

loop diuretics

cause thiamine deficiency

thiazide diuretics

cause urinary zinc losses

phenobarbital

cause increased vit D metabolism

point of care (POC) testing

• POCT has become a billion dollar business

• pharmacists have work under collaborative practice for decades to manage cholesterol and glucose levels

• exploded with COVID-19

• allows a pharmacist to test for certain conditions and provide tx when appropriate

  • need collaborative agreements with providers

  • state protocols that grant autonomous authority

—> POCT needs to be FDA approved and CLIA waived (CLIA = Clinical Laboratory Improvement Amendments)

a cleared POCT test

test that has been cleared by FDA (not approved)

approved POCT test

test that has been approved by FDA

CLIA-waived test

classification of test that uses methodologies that are simple and accurate that

1) likelihood of results with errors are little to none

2) no risk of harm to pt if performed incorrectly

3) approved by FDA for home use

ex: glucometer

exempt test

low risk that the FDA does not require approval

POCT test

test that allow pt dx, screening, or monitoring in hospital/dr office/ambulance…

• need to have results immediately (CAN’T SHIP TO LAB)

pharmacy-based lab testing

• qualitative test

• quantitative test

• rapid diagnostic test

qualitative test

a test that gives results in terms of (-) and (+)

ex: COVID test, flu test, pregnancy test

quantitative test

a test that gives results in numbers

ex: blood sugar test, temp, BP, cholesterol monitor, INR

rapid diagnostic test

a test that is meant to provide immediate diagnostic results

• can be quantitative or qualitative test

VA Test to Treat protocols

Pharmacists have the ability to imitate tx with/dispense/administer of controlled substances

• dispense CII to CVI

• for persons 18 and older

• need a pharmacist-pt relationship

• regulated by Board of Medicine and Department of Health and the Board

available protocols POCT

• tobacco cessation

• coronavirus testing

• vaccines

• TB

• HIV PEP

• HIV PrEP

• hormonal contraception

• Emergency contraception

• prenatal vits

• naloxone

• epinephrine

tobacco cessation POCT

• not testing, but tobacco screening and assessment process

• can prescribe nicotine cessation therapy/non-nicotine cessation therapy for people 18 and older

• pharmacists can notify pt’s PCP and if don’t have PCP, pharmacists can counsel on the benefits of establishing care with PCP

• non nicotine therapy = bupropion or varenicline

• Pharmacists need at least 2 hours of CE training related to prescribing tobacco cessation products

coronavirus testing

• pharmacists may initiate tx/dispense/administer COVID test for pts 18 and older

• require to:

  • have appropriate training on this

  • obtain a history

  • maintain records and report (+) to local/state health dept

  • notify PCP

vaccines

• pharmacists must have knowledge about immunization

• trained in basic CPR

• can issue rx and dispense/administer vaccines for pts 3 and older

• exclusions

  • less than 3 yrs old

  • vaccine is not recommended by CDC

  • pts had received all CDC recommended vaccines

• counsel, record keeping, notify PCP

TB testing

• pharmacists can initiate dispensing/administration/interpretation of TB test for pts 18 and older for

  • those who are at increased risk for latent or active tuberculosis

  • need it for documentation for school, work…

• need required training (must be kept for 6 yrs following last pt)

• counsel and notify (+) to health dept and refer

HIV PEP and PrEP

• PEP = post exposure prophylaxis (after unprotected sex, needle stick…)

• PrEP = pre exposure prophylaxis

• pharmacists can initiate tx/dispense/administer tx for pts 18 and older under FDA regulations

• need to complete training related to prescribing/dispense HIV prevention meds

  • training include trauma-informed care (pts may not go to pharmacy to talk about this, trauma related, rape…)

• counsel, record keeping, notify PCP

hormonal contraception

• pharmacists can prescribe birth control for pts 18 and older

• need to complete Accreditation Council for Pharmacy Edu (ACPE) CE training

• approved for:

  • injectable medroxyprogesterone acetate

  • transdermal patches

  • vaginal rings

  • oral pills

• pharmacists can’t prescribe/dispense to pts beyond 3 yrs from the initial prescription without being seen clinically

  • females need pap smear (also preventive care)

• counsel, record keeping, notify PCP

emergency contraception

• pharmacists can dispense/administer for pts 18 and older

• need at least 1 hour of CE training

• can prescribe approved emergency contraception or OCP for emergency contraception with additional options for management of anti-nausea tx

prenatal vitamins

• can dispense/administer prenatal vitamins for pts 18 and older

• prenatal vitamins approved by FDA

• sometimes insurance will cover if have a rx for this

naloxone

• can write rx/dispense/administer for pts 18 and older (intranasal + intramuscular + injection)

• can be dispensed to those at risk for overdose or to those unable to administer the drugs

• can’t prescribe to:

  • under 18

  • those receiving tx for acute/chronic pain like cancer, sickle cell, in hospice, in palliative care, in clinical trial

• pharmacists must provide a copy of the rEVIVE! Pharmacy dispensing brochure to pts

epinephrine

• to pts 18 and older experiencing anaphylaxis or at risk for experiencing anaphylaxis

most accurate temp tests

• rectal test (rectal is the STANDARD for infants less than 3 months)

• oral test

thermometer characteristics

• age

• preference

• what is available

• accuracy/reliability

What to do with thermometer

• need to disinfect the thermometer after use (use probe cover)

• rectal - for infants less than 1

• oral

• axillary - remain still

• tympanic

• temporal - when we don’t want to wake pts up

What to not do with thermometer

• don’t use a rectal thermometer orally

• don’t use an oral thermometer in pts

  • hyperventilating

  • recent oral surgery

  • lethargic

  • uncooperative

  • <3 y.o.

different types of pain scale

• Wong-Baker FACES pain rating scale

• FLACC scale

• numeric 1-10 pain scale

Wong-Baker FACES pain rating scale

mostly for kids

FLACC pain scale

for

• infants

• nonverbal pts (intubated…)

• neurocognitive deficits

common errors in height

• incorrectly placed stadiometer

• improper positioning

• garments not removed

• inaccurate reading/documentation

common errors in length

• improper equipment use

• improper positioning of pts

  • head not in correct position

  • both legs are not straightened with heels flat

• garments not removed

• inaccurate reading/documentation

weight tools

• infant scale

• bathroom scale

• balance

• wheelchair scale

• bed scale

important notes regarding measuring weight

• need to calibrate scale

• need to weight same time

• need to PEE + remove garments/walker/cane/prosthesis

• safety precautions!

BMI = kg/ (m²)

waist circumference screening

• screening tool for excessive abdominal fat —> CV risk

• higher risks:

  • men >40”

  • non-pregnant women >35”

• need to put measuring tape horizontally around abdomen

• tape is snug, parallel to floor, not compressing the skin

• need to document which guideline you follow (WHO vs. NIH)

common errors in getting weight

• moving on scale

• improper positioning

• garments not removed

• inaccurate reading/documentation

BP

• if repeat BP, wait 1-2 mins before repeating on the same arm

common errors in getting BP

• white coat HTN

• overestimation of BP = HIGHER BP

  • cuff size

  • temp

  • arm position - below

  • anxiety, pain, discomfort, strenuous activity

  • deflating too slowly/too early/halting deflation

• underestimation of BP = LOWER BP

  • underinflation

  • deflating the cup too quickly

  • cuff size

  • arm position - above

hypertensive crisis

sBP >180 OR dBP >110

emergency

ascultatory gap

• silent interval between sBP and dBP

• document completely

Collaborative Practice Agreements (CPA)

allows for prescriptive authority under supervision of a physician according to a protocol

1) pharmacist licensure

2) signed CPA/Protocol with a specific provider based on a Standard of Care (pharmacists are more than just dispensing)

Laws vary by state

provide culturally competent care

• Listen

• Explain

• Acknowledge

• Recommend

• Negotiate

physical exam process

in COLLECT of the PPCP

1) inspection

2) palpation - assess vibration, swelling, rigidity, lumps/masses, pain/tenderness

—> document: SIZE, CONSISTENCY, MOBILITY, NORMAL vs. ABN

3) percussion - assess position, size, density (gas vs. fluid)

4) auscultation

diaphragm of stethoscope

used for high pitched sounds

• breath sounds

• bowel sounds

• regular heart sounds

bell of stethoscope

used for low pitched sounds

• heart murmurs

• bruits

• venous turbulence

• extra heart sounds

• Korotkoff sounds

-ic

-al

pertaining to

para-

beside

eu-

normal

rhinitis

inflammation of the nasal membrane

rhin/o

aphonia

absence of voice

• can be caused by laryngitis

dysphonia

difficulty in speaking or weak voice