[INTRODUCTION] Medication history taking and documentation

Proverbs 16:3

● Expert knowledge on drug and non-drug therapy

● Knowledge on laboratory and diagnostic tests

● Good understanding of disease processes

● Physical assessment skills

● Therapeutic planning skills

● Drug monitoring

● Provision of drug information

● Communication skills

Knowledge & Skills of a Clinical Pharmacist [8]

● Interact with the healthcare team

● Interview and assess the patient

● Review medication orders and make therapeutic recommendations

● Monitor patient response to drug therapy

Roles of a Clinical Pharmacist [4]

● Medication history taking and documentation

● Medication order review

● Reporting and evaluating ADRs

● Therapeutic drug monitoring

● Monitoring of legal, institutional, and other guidelines for drug use

● Drug use evaluation

● Review of cost-effectiveness

● Selection of drug therapy

● Drug information services

● Participate in interdisciplinary clinical meetings, audits, and rounds

● Patient counselling

● Liaison with community service

Clinical Pharmacy Services include [12]

Patient Medication Profile

[MEDICATION HISTORY TAKING AND DOCUMENTATION]

__________-

● Written summary of all medicines taken regularly, including over-the-counter and complementary medicines

●Assist in understanding and managing medicines by informing how, why, and when to take them

Patient Medication Profile (PMP)

[MEDICATION HISTORY TAKING AND DOCUMENTATION]

This is a written summary of all the medicines taken regularly, including over-the-counter and complementary medicines.

Patient Medication Profile (PMP)

[MEDICATION HISTORY TAKING AND DOCUMENTATION]

This assists to understand and manage medicines by informing how, why and when to take medicine.

Medication Reconciliation Process

[MEDICATION HISTORY TAKING AND DOCUMENTATION]

_______-

• This creates the most accurate list possible of all medications a patient is taking (drug name, dosage, frequency, and route)

• This is being compared against the physician's admission, transfer, &/ discharge orders with a goal of providing correct medications.

Patient Medical Chart (PMC)

[MEDICATION HISTORY TAKING AND DOCUMENTATION]

This contains all significant clinical information which enables the physician to give effective continuing care to the patient.

● Patient Data Sheet

- Patient demographics

- Admission & final diagnosis

- Condition upon discharge

● Consent form

● History

● Physical Examination

● Physician's Order Sheet

- Doctor's progress notes

- Doctor's orders

● Consultation, Examination, and Findings

● Graphic Chart

● Fluid input and output record

● Medication Administration Record

● Multidisciplinary Progress Notes

● Laboratory Results

[MEDICATION HISTORY TAKING AND DOCUMENTATION]

Parts of Patient Medical Chart (PMC) [11]

● Patient demographics

● Admission & final diagnosis

● Condition upon discharge

[PATIENT MEDICAL CHART]

Patient Data Sheet includes the following patient information [3]

Consent form

[PATIENT MEDICAL CHART]

This refers to the permission or approval given by patient for admission, testing, procedure and access to health related or personal information.

● Chief complaint

● History of Present Illness

● Past Medical History

● Family History

● Social History

● Review of Systems

[PATIENT MEDICAL CHART]

Patient's History include [6]

Chief complaint

[PATIENT MEDICAL CHART]

This is the patient's subjective statement of their main health concern or problem.

Social History

[PATIENT MEDICAL CHART]

This is related to the patient's work, habits, lifestyle, alcohol and tobacco use, and any history of substance use or addiction.

Review of Systems

[PATIENT MEDICAL CHART]

This refers to the systematic evaluation of all body systems, covering past and current conditions except those already detailed in the History of Present Illness.

Physical Examination

[PATIENT MEDICAL CHART]

This is a brief, systematic assessment of the patient's body to evaluate the function and condition of each organ system.

● Body Temperature

● Pulse rate

● Respiratory rate

● Blood pressure

[PATIENT MEDICAL CHART]

Vital signs include _____ [4]

37.5 °C ± 0.5 °C

[PATIENT MEDICAL CHART]

Normal body temperature:

●Tympanic

● Axillary

● Rectal

● Oral

📌Mnemonic: “TARO”

[PATIENT MEDICAL CHART]

Body temperature checking methods [4]

Oral

[PATIENT MEDICAL CHART]

The most accessible method of taking temperature, but less accurate.

Rectal

[PATIENT MEDICAL CHART]

The most accurate method of taking temperature, reflecting core body temperature, but least convenient and invasive.

Axillary

[PATIENT MEDICAL CHART]

The safest method of taking temperature, non-invasive, but generally the least accurate.

60-100 beats/min

[PATIENT MEDICAL CHART]

Normal pulse rate:

● Radial artery

● Femoral artery

● Carotid artery

[PATIENT MEDICAL CHART]

Common sites for checking pulse [3]

Radial artery

[PATIENT MEDICAL CHART]

________-

• Located at the wrist

• Most commonly used for routine pulse checks

• Accessible and convenient.

● Femoral artery

● Carotid artery

[PATIENT MEDICAL CHART]

These arteries are used in emergency situations [2]

● Bradycardia

● Tachycardia

[PATIENT MEDICAL CHART]

Abnormal findings in pulse rate [2]

16-20 breaths/min

[PATIENT MEDICAL CHART]

Normal respiratory rate:

● Prolonged expiration - Suggests narrowing of the bronchioles

● Wheezing or stridor - Abnormal respiratory sounds

● Apnea - Temporary cessation of breathing

● Bradypnea - Abnormally slow breathing

● Tachypnea - Abnormally fast breathing

[PATIENT MEDICAL CHART]

Abnormal findings in respiratory rate [5]

<120/80 mmHg

[PATIENT MEDICAL CHART]

Normal blood pressure:

● Hypertension (HTN)

● Cardiac disease

● Orthostatic hypertension (Orthostatic HTN)

● Venous congestion/Hypertension

[PATIENT MEDICAL CHART]

Abnormal findings in blood pressure [4]

Venous congestion

[PATIENT MEDICAL CHART]

This refers to a silent period of hypertension.

● Inspection

● Palpation

● Percussion

● Auscultation

[PATIENT MEDICAL CHART]

Physical Assessment Techniques include [4]

Inspection

[PATIENT MEDICAL CHART]

This physical assessment technique refers to the visual examination of the patient.

Palpation

[PATIENT MEDICAL CHART]

This physical assessment technique involves the use of the hand to feel skin texture and contour, masses below the surface, as well as temperature and vibration (light and deep).

Percussion

[PATIENT MEDICAL CHART]

This physical assessment technique is used to elicit a sound which reflects the density of underlying tissue and structures by tapping the body directly or a finger placed on the body (dull percussive sounds, hyperresonance on percussion).

Dull sound

[PATIENT MEDICAL CHART]

This sound in percussion indicates dense tissue (liver, consolidation in lungs).

Resonant or hyperresonant sound

[PATIENT MEDICAL CHART]

This sound in percussion indicates air-filled spaces (e.g., normal lungs, emphysematous lungs).

Auscultation

[PATIENT MEDICAL CHART]

This physical assessment technique involves listening to sounds produced by the body, usually from internal organs.

● Direct - Listening directly with the ear

● Indirect - Listening using a stethoscope

Inspection

↓

Palpation

↓

Percussion

↓

Auscultation

[PATIENT MEDICAL CHART]

General sequence of physical assessment technique [4]

Inspection

↓

Auscultation

↓

Percussion

↓

Palpation

[PATIENT MEDICAL CHART]

General sequence of abdomen assessment technique [4]

● Doctor's progress notes

● Doctor's orders

[PATIENT MEDICAL CHART]

Physician's Order Sheet includes [2]

Documentation

[MEDICATION HISTORY TAKING AND DOCUMENTATION]

The means by which healthcare professionals communicate with one another.

● SOAP (subjective, objective, assessment, plan)

● FARM (findings, assessment, resolution, monitoring)

[MEDICATION HISTORY TAKING AND DOCUMENTATION]

Documentation used in clinical pharmacy [2]

SOAP

[MEDICATION HISTORY TAKING AND DOCUMENTATION]

This documentation is used widely in medical and clinical settings.

FARM

[MEDICATION HISTORY TAKING AND DOCUMENTATION]

This documentation used mostly in pharmacy or medication-focused documentation.