Collecting Information

Question 1

How can you collect information for a patient?

Answer 1

• Review Patient chart
• Utilize drug information resources (Micromedex, Lexicomp)
• Communicate with…
• Patient: listen to what is said and how it is said–> observe what is done
• other providers

Question 2

Where do we start collecting medication information in an outpatient setting?

Answer 2

• PMH
• It is important to collect the med history for patients
• What has the patient had problems with in the past?
• What are the ongoing/current problems?
• Have there been any recent doctor’s visits, ER visits, or hospital admissions?

Secondly.,.
* Collect the social history, including smoking status, alcohol status, and other drugs of abuse

Third…
* Collect allergies and document them

Fourth…
* What are the current meds?
* What is documented?
* What is listed in notes?
* Why are they on each med?
* Is the dose appropriate for disease control?
* Is the dose appropriate based on renal function?
* are any disease states missing meds?

Fifth…
* Vital Signs
* What were they at the last visit?
* What is their pattern?
* Anything contruubuting to cause abnormalities
* Potential changes to meds to achieve goals

Sixth…
* Lab Values
* Need to know normal ranges
* When were they last checked
* are updated labs needed to make more accurate assessment or plan
* If not at goal, what is the next step for medication management?
* Assess other recent abs for appropriateness
* Are there other labs that should be ordered for general screening based on patient age/risk factos?

Question 3

Where do you start collecting information for inpatient care?

Answer 3

1. Thoroughly review med profiles
2. Create a problem list with recommended pharmacotherapy plan and monitoring for each patient
3. Concisely present a patient to preceptor

Question 4

How to thoroughly review medication profiles?

Answer 4

Assess…
1. the appropriateness of therapy
2. renal dosing changes
3. Side effects
4. IV to PO switches
5. appropriate antibiotic selection
6. appropriate pain relief/bowl regimen
7. Prophylaxis needed? medications to prevent injury
8. monitor insulin requirements
9. use of prn meds
10. drug interactions
11. contraindications to therapy

Question 5

Where to continue for inpatient care?

Answer 5

1. Create a problem list with plan and monitoring for each patient
2. Admission (chief complaint, history of present illness, social history, medication history)
3. Daily (culture results and prior/current antibiotics including # of days, know creatinine clearance, prn medications used including number of doses, pertinent labs, vitals, and overnight events)
4. LAST STEP- Problem list and treatment plan that lists disease state, correlates drugs with appropriate disease state, identifies any drugs that don’t have an indication, start identifying recommendations