documentation of pharmacotherapy interventions Flashcards
is required to record pertinent facts, findings, and observations about a patient’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes
documentation
responsible provision of drug therapy for the purpose of achieving definite outcomes that improves a patient’s quality of life
Hepler and Strand, 1990
pharmaceutical care
a patient-centered practice in which the practitioner assumes responsibility for a patient’s drug related needs and is held accountable for this commitment
Cipolle, 1998
pharmaceutical care
pharmaceutical care major functions
- identify potential and actual drug-related problems
- resolve actual drug-related problems
- prevent potential drug-related problems
pharmaceutical care expected outcomes
- cure disease
- eliminate or reduce symptoms
- arrest or slow down disease process
- prevent disease or symptoms
3 components of pharmaceutical care plan
- assessment
- plan
- monitoring
a review of the medical conditions and symptoms to determine the need for drug therapy
assessment
a decision of an appropriate drug therapy based on the assessment of the patient
plan
a review of the outcomes of drug therapy to determine if the patient is obtaining the desired outcomes
monitoring
a distinct service or group of services that optimize therapeutic outcomes for individual patients
medication therapy management
patient centered assessment and evaluation of the patient’s full medication regimen and not only individual medications
medication therapy management
MTM
4 goals of medication therapy management
MTM
- optimize medication use
- improve collaboration
- enhance communication
- empower patients
5 core elements of medication therapy management
MTM
- medication therapy review (MTR)
- personal medication record (PMR)
- medication-related action plan (MAP)
- intervention and/or referral
- documentation and follow-up
a systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them
medication therapy review
MTR
a comprehensive record of the patient’s medications (prescription and non-prescription medications, herbal products, and other dietary supplements)
personal medication record
PMR
DOCUMENTATION CATEGORY
basic information: address, phone, e-mail, gender, age, ethnicity, education status, patient’s special needs, health plan benefit/insurance coverage
patient demographics