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

Patient Care Process

Collect = GET information
Plan = PICK
Implement = DO
Follow up = CHECK

Throughout:

Collaborate + Communicate + Document

Center:

Person-Centered Care

Pharmacist assesses whether therapy is:

• safe/effective

• indicated/convenient/economical

When collect, what topics covered?

• Subjective - patient/caregiver TELLS you

  • Healthy History

    • HPI → SCHOLAR goes HERE

  • Medication History

    • MAC

• Objective- observable

• QuEST - overall self-care assessment process

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

tell me more about the problem

→ SCHOLAR

→ include relevant pertinent negatives

 Health History

PMH

Previous/current medical conditions.

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

 Health History

Family History

Parents → siblings → children

 Health History

Social History

• Alcohol/Smoking/drugs

• Diet/Exercise

 Health History

ROS

Additional patient-reported symptoms

ROS = patient says it

Physical exam = provider observes it

 Medication History

• Ask about everything the patient takes: Rx + OTC + supplements/natural products

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

  → identify/address adherence first

• MAC

• → indication / dose / schedule
  → allergies / ADRs
  → adherence

  
  

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 - bulk of SCHOLAR

H = History

O = Onset

L = Location

A = Aggravating factors

R = Remitting factors

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

MAC

M = Medications

→ prescription + nonprescription + natural products

A = Allergies

C = Conditions

Patient Assessment

THINK

Look at S/O → analyze → identify Medication Therapy Problem:

• Indication

• Effectiveness

• Safety

• Adherence

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/non-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

rules for HOW to write the Assessment:

• prioritize problems

• goal of therapy

• Relevant support

• NO new info.

If you write:

“The patient reported…”

→ it probably belongs in…

Subjective first.

Plan

what you're going to do; PICK

Include:

• Pharmacologic

• Nonpharmacologic

• Monitoring

• Follow-up timeframe

  • specific timeframe

  • Follow-up is essential and commonly forgotten.

how you DOCUMENT everything

SOAP

S = Subjective

→ patient/caregiver information

O = Objective

→ observed info

A = Assessment

→ analysis S + O

P = Plan

→ actions taken/needed to resolve problems