Chapter 28 Patient Assessment Flashcards
PPCP
Pharmacists’ Patient Care Process
developed by the Joint Commission of Pharmacy Practitioners alongside other
major pharmacy organizations and key stakeholders.
Pharmacists’ Patient Care Process
five elements that should be incorporated by pharmacists practicing patient-centered
care:
Collect Assess Plan Implement Follow-up:Monitor/Evaluate
reason for the
patient’s visit.
Chief complaint (CC)
the onset of the
illness and modifying factors.
History of present illness (HPI)
all medications taken by any route
Medications, allergies, and immunizations:
patient’s family medical
history,
Family history
patient’s social activities
that may relate to the presented illness
Social history
This information is usually arranged by organ system (i.e. gastrointestinal, respiratory, musculoskeletal)
ROS
Problem-Focused Interview
open-ended questions
and statements.
this method allows the patient to elaborate on his or her
condition
Seven basic screening questions
may be used in the interview
LAST QSM Location Quality Severity Timing Setting Modifying factors Associated symptoms
Where is the symptom?
Location:
What is it like? Describe it.
Quality:
How bad is it? How does it interfere with your life?
Severity:
How long has it been present? When did it start? How often does it occur?
Timing:
How did it happen? What were you doing when it started?
Setting:
What makes it better or worse? What did you use to
treat it?
Modifying factors:
What other things have you noticed?
Associated symptoms:
four identifiable sections that interview information should be organized to:
SOAP
all the information
reported by the patient as presented.
Subjective
health care provider’s
physical or mental observations,
Medications may be listed here
if not reported by the patient.
Objective
health care provider’s evaluation
and diagnosis of the case presented
Assessment:
the health care provider’s treatment plan
and recommendations, the medication prescribed or discontinued, and
the patient counseling performed. It should include follow-up visits and
monitoring recommendations for the patient.
PLAN
Follow-up visits should include an
interim interview
4 main issues in an interim interview
control
adherence
complications
symptoms range
general observation of the patient
Inspection
use of the of touch for evaluation-brevity
palpation
skin surfaces
light touch
organs or masses
deeper touch
fine, tactile sensation
fingertips
temperature
dorsal surface of the hand
Vibrations
palm surface at the metacarpal joints
deep palpation, including the palpation
of organs.
finger pads
assessing strength
two fingers or whole hand
used to produce sounds, elicit tenderness, or assess reflexes in a patient.
locating organ borders, identifying organ shape
and position, and determining whether an organ is solid or filled with gas.
direct or indirectly
Percussion
tapping a finger against the middle finger
Indirect percussion
striking a fist
blunt percussion
tympanic-drum sound
gas bubble
hyperresonant/boom-like
emphysematous lung
resonant/hollow
healthy lung
