pharmacotherapy interventions - midterm Flashcards
It involves using medications to treat or manage a patient’ s medical condition. Documenting these interventions effectively is crucial for ensuring patient safety, continuity of care, and clear communication among healthcare
professionals.
Pharmacotherapy interventions
Key elements for thorough documentation
• Patient Information
• Intervention Information
• Additional Considerations
Patient Information includes:
• Patient name and identification number
• Date of encounter
Intervention information includes:
• Medication
• Indication
• Duration of Therapy
• Monitoring Plan
• Generic name and brand name (if
applicable)
• Dosage form (tablet, capsule, liquid,
etc.)
• Dosage (amount and frequency)
Route of administration (oral,
intravenous, etc.)
Medication
The specific reason for prescribing the medication (e.g., treatment of peptic ulcer, prevention of nausea and vomiting during chemotherapy)
Indication
How long the patient should take the medication (e.g., 2 weeks, until symptoms resolve)
Duration of Therapy
Outline any specific monitoring requirements, such as blood tests, to assess the medication’s effectiveness and address potential side effects.
Monitoring Plan
Additional Considerations include:
• Allergies
• Reasoning for Selection
• Patient Education
• Response to therapy
Document any known allergies the patient has to medications or medication classes.
Allergies
Briefly explain why this particular medication was chosen for the patient’s condition, considering factors like allergies, potential interactions with other medications, and the patient’s medical history.
Reasoning for Selection
Document any patient education provided regarding the medication, including dosage instructions,
potential side effects, and storage
recommendations.
Patient Education
As the patient continues treatment, document their response to the medication. This includes noting any improvement in symptoms, side effects experienced, and any necessary adjustments to the medication regimen.
Response to therapy
Documentation Methods
• Electronic Health Records (EHR)
• Progress Notes
• Medication Administration Records (MAR)
Most healthcare providers use EHR systems that allow for standardized documentation of medication orders, allergies, and patient education materials.
Electronic Health Records
Written ___ can be used to document the rationale for medication selection, response to therapy,
and any adjustments made.
progress notes
These record the specific medications administered to a patient, dosage, route, and time of administration.
Medication administration records
(MAR)
Importance of Documentation
• Regulatory Compliance
• Improved Patient Care
• Medico-legal purposes
Documentation serves as a medico-legal record of the care provided to the patient.
Medico-legal purposes
Clear documentation facilitates
communication between healthcare
providers, reduces the risk of medication errors, and allows for better monitoring of treatment effectiveness.
Improved Patient Care
Accurate documentation is essential for meeting regulatory requirements and standards of practice.
Regulatory Compliance
These programs aim to optimize medication use and improve patient health outcomes.
Documentation in this is even more crucial compared to standard medication interventions, as it focuses on comprehensive medication review and personalized care plans.
Medication Therapy Management (MTM)
Benefits of Comprehensive Documentation
• Improved Patient Outcomes
• Enhanced Communication and Collaboration
• Demonstration of MTM value
Comprehensive documentation helps
demonstrate the effectiveness of MTM programs in improving patient
medication use and health outcomes.
Demonstration of MTM value
Clear documentation promotes a more collaborative approach to medication management among healthcare providers.
Enhanced Communication and Collaboration
Detailed documentation allows for better tracking of progress, identification of potential issues, and facilitates
ongoing communication between the pharmacist, physician, and patient.
Improved Patient Outcomes
Similar to standard interventions, EHR
systems, progress notes, and MTM-
specific templates can be used for
documentation.
However, MTM programs may have specific documentation requirements or utilize standardized tools to assess
medication adherence and patient
outcomes.
Consider factors like access to food, transportation, and social support that can influence medication adherence and health outcomes.
Social Determinants of Health
Document the patient’s ability to perform daily activities and how medications may be impacting their functional independence.
Functional Status
Outline the plan for monitoring the patient’s progress and making any necessary adjustments to the medication regimen.
Follow-up Plan
Detail the specific actions taken during the MTM encounter to address MRPs and achieve patient goals.
This may involve medication adjustments, dose modifications, recommendations for discontinuing unnecessary medications, or referrals to other healthcare providers.
Interventions
These are any issues that can arise from medication use, such as duplication,
adherence problems, or potential side effects.
MTM focuses on identifying and addressing these MRPs. Document each
identified MRP.
Medication-related problems
Include the patient’s specific goals for MTM, such as improving symptom control, reducing medication burden, or
managing a chronic condition more effectively.
Patient Goals
Document any past medications the patient has taken, including reasons for discontinuation and any adverse reactions experienced.
Medication history
Same information as standard documentation (generic/brand name, dosage form, dosage, route, etc.) but with an added focus on: Over-the-counter (OTC) medications and herbal supplements:
Medications
MTM goes beyond prescription medications to include a complete picture of all medications and supplements a patient is taking.
Over-the-counter (OTC) medications and herbal supplements:
NOTE:
By adhering to these principles and using appropriate documentation strategies, pharmacists can ensure MTM services are well-documented, leading to better patient care, stronger collaboration within the healthcare team, and a clearer picture of
the program’s impact on patient health.
