Pharmacist Patient Care Process Flashcards
Triple Aim
Improved patient experience
Reduced Cost
Improved population health
Patient and Family Centered Care (PFCC)
Collaborative approach to health care that involves patients, families, and providers
Patient Care Process
Collaboration
Communication
Documentation
Collaboration
Working together to achieve common goal
More common in hospitals
Most communication will be with patients in
self-care encounters
Documentation
Contribution and continuity of care
Legal evidence
Collect
Subjective and objective information about patient
Subjective information
Information provided by patient
Objective information
Information observed or measured in medical or lab reports
CC
Chief Complaint
HPI
History of Present Illness
PMH
Past Medical History
PSH
Past Surgical History
FH
Family History
MH
Medical History
SH
Social History
MedHx
Medication History
NKDA
No Known Drug Allergies
ROS
Review of Systems
PE
Physical Examination
Lab and Diagnostic
Laboratory Value and Imaging
SOAP
Subjective, Objective, Assessment, Plan
General Patient Information
Date, time, setting of history
Demographics/personal history
Chief Complaint (CC)
Major reason for seeking medical attention
Patient’s own words in quotes
Duration of problem
History of Present Illness (HPI)
Thorough description and expansion of CC
Onset of problem
7 characteristics
Seven Characteristics
Timing
Location
Quality or character
Quantity or severity
Setting
Aggravating or relieving factors
Associated symptoms
Past Medical History (PMH)
General Health
Childhood/adult illnesses
Immunizations
Allergies
ADRs
Past Surgical History (PSH)
Surgeries, hospitalizations, injuries, transfusions
Social History (SH)
Tobacco/alcohol use
Drug use
Health habits
Education/employment
Family History (FH)
Presence or absence of illness in patient’s first degree relatives
Review of Systems (ROS)
Summarizes all current patient complaints
Organ system approach
Physical Examination (PE)
Vital signs
Skin –> Extremities
Lab and Diagnostic Tests
Serum electrolytes: Chem 7
Complete Blood Count (CBC)
Diagnostic Tests
Medication/Drug Related Problems (MRP/DRP)
DRP is undesirable event experienced that involves drug therapy and interferes with desired outcomes
Common DRPs
Unnecessary drug prescribed
Wrong drug
Dose too low/high
ADE
Non-adherence
Additional drug therapy
SBAR
Situation, background, assessment, and recommendation
Assessment
Appraisal of each problem, therapeutic goals/endpoints, appropriateness of drug therapy
Plan
Treatment and monitoring plan for each active problem
SCHOLAR-MAC
Symptoms
Characteristics
History
Onset
Location
Aggravating Factors
Remitting Factors
Medications
Allergies
Medical Conditions
what falls under subjective information?
chief complaint
history of present illness
past medical history
social history
family history
review of systems
what falls under objective information?
medication list
vital signs
physical exam
laboratory values
diagnostics
Plan includes
treatment plan
education and counseling
monitoring, follow up and referrals
does medication list fall under just objective information?
no!
it can fall under subjective if provided verbally by the patient
what is included at the end of a SOAP note?
references and signature
