(1) Patient Assessment Process, Health and Medication Histories, SOAP notes, TBL explanation

Patient Care Process

Collect → Assess → Plan → Implement → Follow Up/Monitor & Evaluate

Throughout:

Collaborate + Communicate + Document

Center:

Person-Centered Care

Pharmacist assesses whether therapy is:

Indicated → Effective → Safe → Convenient → Economical

When collect, what topics covered?

• Subjective

  • Health History

    • SCHOLAR

  • Medication History

    • MAC

• Objective

• QuEST

Patient Assessment

Assessment = analyze + interpret + evaluate S/O

→ identify medication-therapy problems

→ determine what needs to be done.

Subjective vs Objective

Subjective = patient/caregiver TELLS you

Objective = measurable, observable, or verified

Objective examples:

• Vitals

• Labs

• Imaging

• Physical exam

• Verified medication records

What can be S or O?

Medication history

Adherence

Patient tells you medication →

Medication verified in chart/pharmacy →

Patient says they miss doses →

Fill history shows late refills →

Patient tells you medication → Subjective

Medication verified in chart/pharmacy → Objective

Patient says they miss doses → Subjective

Fill history shows late refills → Objective

Health History Components

Demographics → CC → HPI → PMH → Family Hx → Social Hx → ROS

 Health History

CC

Chief complaint = patient's main concern in their own words

→ use quotes

 Health History

HPI

Details/history surrounding the chief complaint

→ SCHOLAR goes here

→ include relevant pertinent negatives

 Health History

PMH

• Current disease states

• Relevant previous conditions/history

⭐ For THIS CLASS: PMH → Subjective, even if it is also in the chart.

 Health History

ROS

Additional patient-reported symptoms

ROS = patient says it

Physical exam = provider observes it

 Medication History

• Rx medications/OTC medications/Supplements

• Name/Indication/Dose/Schedule/Duration

• Outcome/effectiveness

• Tolerability

• Allergies vs. ADRs

• Adherence

Medication History

what not same?

may be adverse effect/intolerance, not necessarily a true allergy.

Medication History

Adherence

Don't automatically add another medication if the patient isn't taking the current medication.

→ identify/address adherence first.

COLLECT

QuEST

Q = Quickly and accurately assess patient

E = Establish appropriate self-care candidate

S = Suggest appropriate self-care strategies

T = Talk with patient

COLLECT

SCHOLAR

S = Symptoms

C = Characteristics

H = History

O = Onset

L = Location

A = Aggravating factors

R = Remitting factors

SCHOLAR → HPI

⭐ Professor specifically called this material “super important.”

Also understand:

• Symptoms → what symptoms?

• Characteristics → describe them

• History → happened before? tried anything?

• Onset → when did it start?

• Location → where?

• Aggravating → what makes it worse?

• Remitting → what makes it better?

COLLECT

What is the bulk of SCHOLAR?

Characteristics

COLLECT

MAC

M = Medications

→ prescription + nonprescription + natural products

A = Allergies

→ medication + other allergies

C = Conditions

→ medical conditions

MEDICATION THERAPY PROBLEMS

INDICATION

• Unnecessary medication therapy

• Needs additional medication therapy

EFFECTIVENESS

• Ineffective medication

• Dosage too low

• Needs additional monitoring

SAFETY

• Adverse medication event

• Dosage too high

• Needs additional monitoring

ADHERENCE

• Adherence

• Cost

You MUST be able to distinguish them

1. Doesn't need drug

2. Needs a drug

3. Drug isn't working adequately

4. Right drug, but not enough

5. Need to check effectiveness/safety

6. Drug caused a problem

7. Too much drug / excessive frequency

8. Not taking as intended

9. Affordability problem

1. Doesn't need drug → Unnecessary medication therapy

2. Needs a drug → Needs additional medication therapy

3. Drug isn't working adequately → Ineffective medication

4. Right drug, but not enough → Dosage too low

5. Need to check effectiveness/safety → Needs additional monitoring

6. Drug caused a problem → Adverse medication event

7. Too much drug / excessive frequency → Dosage too high

8. Not taking as intended → Adherence/non-adherence

9. Affordability problem → Cost

Assessment rules:

1. Interpret S + O — don't just repeat them

1. Include relevant supporting information

2. Include goal of therapy

1. Prioritize problems by importance/acuity

2. NO new information in Assessment

If you write:

“The patient reported…”

→ it probably belongs in…

Subjective first.

Plan

what you're going to do

Include:

• Plan to achieve goal

• Nonpharmacologic recommendations

• Pharmacologic recommendations

• Monitoring/follow-up - Give a specific timeframe:

• 
  

⭐ Follow-up is essential and commonly forgotten.

SOAP

S = Subjective

→ patient/caregiver information

O = Objective

→ measurable/verified data

A = Assessment

→ analysis/interpretation of S + O

P = Plan

→ actions taken/needed to resolve problems