Patient Assessment Processes, etc Flashcards
Social Determinant of Health
conditions in the place where people live, learn,work, and play that affect a wide range of health and quality-of-life-risks and outcomes
Examples of SDOH
Economic stability Neighborhood and Physical Environment Education Food Community and Social context Health care systems
Prejudice
A preconceived opinion that is not based on reason or actual experience
Bigotry
Intolerance toward those who hold different opinions or are different from oneself
Discrimination
The unjust or prejudicial treatment of different categories of people or things, especially on the grounds of race, age, or sex
Racism
Prejudice, discrimination, or antagonism directed against a person or people on the basis of their membership of a particular racial or ethnic group, typically one that is a minority or marginalized
Implicit Bias
attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner
What is transition of care?
when patient leaves care of particular unit or health care facility and moves to another facility, setting or their own home
Poorly coordinated Transition of care can cause….
med discrepancies
readmissions
adverse events
Higher costs
Pharmacist role in TOC
Admin = taking best possible med history
During hospital = optimize drug therapy
Discharge = perform med rec
after discharge = follow up
JCPP Patient Care Process
Collect Assess Plan Implement Follow up: Monitor and Evaluate
JCPP Patient Care Process: Collect
Med terms/abbreviations Med history Med Rec Lab results Pt lifestyle habit, preferences, beliefs Socioeconomic factors
JCPP Patient Care Process: Assess
clinical data interpretation Risk factors Pt specific outcomes Health literacy Access to meds preventative health ID problems Develop problems list
JCPP Patient Care Process: Plan
address problems and make recommendations using evidence based med
ID goals of therapy to achieve clinical outcomes
JCPP Patient Care Process: Implement
Initiate, modify, DC med therapy
Pt ed and self management training
Preventative care strategies
JCPP Patient Care Process: Follow up
Monitor clinical endpoints
monitor outcomes of care/care goals
Re-eval each encounter
Quest Scholar-MAC
QUick and accurately assess the patient
E- estabilsit if patient appropriate for OTC therapy
S- Suggest appropriate therapy
T-Talk w/ patient
S- Symptoms C- Characteristics H- History O- Onset L- Location A- Aggravating factor R- Remitting factors
M- Other meds
A- Allergies
C - Coexisting conditions
SOAP
Subjective
Objective
Assessment
Plan
Subjective
described by patient themselves
cannot be reliably reproduced
Objective
observations made and info acquired by HC practitioner
ex. lab results, tests, vital signs
Assessment
Practitioners clinical opinion or judgement about problem
find problems
include rational for therapy recommendations
Plan
Course of actions deemed appropriate for each problem
concise
Do not use list
U (unit) IU (International Unit) Lacking 0 or trailing 0 QD,QOD MS, MSO4
Info on intervention form?
Name Date Time Intervention category Clinical Significance Outcomes Response
Progress Note Structure
- Descriptor/Chief Complaint
- Prioritized Problem List
- Subjective/Objective section
- Assessment Section
- Plan Section
Steps to answer physician calling
- ID the requestor
- Obtain background info
- eval, analyze, and synthesize info found
- Determine ultimate question
- Develop strategy and conduct search
- Formulate and provide response
- Conduct follow-up
