Intro Flashcards
Drug-Related Problems (DRPs)
Any undesirable event experienced by
the patient that:
- involves drug therapy AND
- interferes with a desired patient outcome
A patient problem that is either:
- caused by a drug OR
may be treated with a drug
Pharmaceutical Care
RESPONSIBLE provision of drug therapy to
achieve patient outcomes
Cure or prevent disease
Improve or prevent symptoms
IDENTIFY and RESOLVE drug-related
problems
Centered around the PATIENT!
History & Physical (H&P) Exam
Chief complaint (CC) History of present illness (HPI) Past medical history (PMH) Family history (FH) Social history (SH) Allergies Medications prior to admission Review of systems (ROS) Physical examination (PE) Laboratory data and diagnostic testing
History & Physical (H&P) Exam
How information is organized once
obtained from the patient
Medical charts
Your patient presentations
Chief Complaint (CC)
Describe why the patient is seeking
care in the patient’s own words
Complaint - My back is aching and I cannot walk Goals - I've come in for a refill of my blood pressure medicine.
History of Present Illness (HPI)
- Expands upon the CC
- Chronological account of issues prompting the
patient to come to the hospital, clinic, pharmacy, etc. - Onset of issue
- Symptoms
- Setting in which it developed
- Clinical manifestations
- Self-treatment
- Pertinent positives
- Pertinent negatives
Patient will provide a lot of information that may be
disorganized - Needs to be organized into a coherent, systematic HPI
Past Medical History (PMH)
Childhood illnesses Adult illnesses - Chronic medical conditions/hospitalizations/injuries- e.g.: DM, HTN, HIV - Obstetric/Gynecologic history - Psychiatric history - Surgical history (PSH) - Types of surgery, dates Health maintenance - Immunization history - Screening tests (TB, Pap smears, mammograms, etc.)
Family History (FH)
Document information about each of the patient's family members (parents, grandparents, siblings, children, grandchildren) - Age - Current health status or cause of death - Chronic medical conditions Documentation methods - F↓ 67 MI - M ^ DM2
Social History (SH)
Birthplace Occupation Home situation/living conditions Lifestyle situation - Use of alcohol, caffeine, tobacco - Use of illicit drugs - Sexual activity - Exercise and nutrition Last year of schooling/education Leisure activities Activities of daily living
Allergies
Medications
- Specific reaction
- When
- How treated
- Allergic reaction versus adverse drug reaction
- Seasonal
- Food
Medication History
Medications - RX - OTC - Alternative therapies Be specific - Doses, routes of administration, duration of treatment, reason for use - As needed medications: frequency of use, quantity of use - Compliance
Review of Systems (ROS)
Review of patient's symptoms by organ system - Obtained from the patient (subjective) Reviews from head to toe - Identifies additional symptoms not revealed in previous sections -Presence (+) or absence (-) of symptoms should be documented May be general or specific
Physical Examination (PE)
Head to toe examination
- Performed by practitioner (objective)
Typically begins with a short description
of the patient followed by vital signs
Positive and negative findings are
reported
Clinical Assessment &
Plan for Management
SOAP note
PHARME note
