Exam 1 Flashcards
(95 cards)
1
Q
Attributes of a profession
A
Systematic theory and body of knowledge
Professional authority and privileges
Community sanction and social utility (licensure)
Ethical (& professional) codes and internal control
Professional culture and organizations
2
Q
Altruism
A
Commitment
Compassion
Generosity
Perseverance
Gives full attention to patients
Cooperates with other professionals
Sensitive to social issues
3
Q
Equality
A
Fairness
Self-esteem
Tolerance
Provides services based on needs
Relates to others without discriminating
Provides leadership in improving access
4
Q
Truth
A
Honesty
Accountability
Rationality
Gives accurate information
Documents actions accurately
Protects public from misinformation
5
Q
Justice
A
Integrity
Morality
Acts as patient and healthcare advocate
Allocates resources fairly
Reports incompetent, unethical, and illegal practices
6
Q
Dignity
A
Empathy
Kindness
Trust
Respects right to privacy
Maintains confidentiality
7
Q
Freedom
A
Self-direction
Self-discipline
Respects each individual’s autonomy
8
Q
Role of Pharmacist
A
“Clinical problem-solver”
9
Q
Goal of Pharmacist
A
Improve patient’s outcome
10
Q
Role of Pharmacist
A
Healthcare professional
Commercial businessman
Commercial environment may contradict ideals of professional practice leading to disillusionment & disenchantment
11
Q
1965-1990
A
Clinical Pharmacy Era
12
Q
1990-present
A
Pharmaceutical Care Era
13
Q
Pharmaceutical Care
A
Description:
Patient-centered delivery of medication management services
Stresses pharmacist’s accountability for optimal drug therapy outcomes:
Cure of a disease
Elimination or reduction of symptoms
Arresting or slowing a disease process
Preventing a disease or symptom
14
Q
Pharmacist’s Patient Care Process
A
Collect Assess Plan Implement Follow-up: Monitor and Evaluate
15
Q
In everyday terms…
A
Evaluates a patients drug-related needs
Determines the presence of actual or potential drug related problems
Works with the patient and other professionals to design, implement, and monitor a care plan that will resolve or minimize the drug related problems
16
Q
In an ideal world…
A
Providing pharmaceutical care means that, at the end of the day, pharmacists measure their success by how many people they have helped, not by how many prescriptions they have filled.
17
Q
“Reasonable person” concept
A
Requires one to act with the same degree of care, knowledge,
expertise, fairness, and awareness of the law that the community
would expect of a hypothetical “reasonable” person.
Negligence law: behavior falling below standard triggers liability.
Purpose = public good
18
Q
Examples of Pharmacist impact
A
Improved ability to reach target INR and avoid over-
anticoagulation with warfarin
Increased flu immunization rates
Improved compliance and blood pressure control in hypertensive
patients
19
Q
Enablers of Optimal Pharmacy Practice
A
Evidence supporting the positive impact of pharmacist on
patient outcomes.
Increasing number of pharmacy students pursuing residencies.
Increasing number of BCPS pharmacy specialists.
National focus on quality and safety.
20
Q
Barriers to Optimal Pharmacy Practice
A
Opposition from some physician organizations.
Pharmacy leadership shortage.
Financial constraints in health systems and reductions in
pharmacy staffing levels.
Pharmacist’s resistance to change.
Lack of qualified technicians.
Reimbursement strategies based on product and productivity.
21
Q
Change and Survival
A
Faster and more efficient technology.
Increasing trend toward mail-order.
22
Q
Conclusions
A
Central concept of pharmaceutical care is accepting
responsibility for the outcome of medication, services and drug
information provided to patients.
Represents a systematic process designed to determine patient-
specific needs and identify and resolve drug-related problems.
23
Q
Information Sources for Medication History
A
Patient/client
Family or caregivers
Medication vials/medication boxes/blister cards (compliance, dose, what pharmacy)
Medication list (not always current)
Pharmacy records (more updated)
Medication profile or medication administration record from other facility (also has PRN meds (nursing home))
DPIN (Drug Programs Information Network)
Hospital discharge list (if seen again within a short amount of time)
*NHHI- anywhere in NE that uses this system and if patient signs a release form. Provider will have access to med list, etc.
24
Q
Medication History Challenges
A
Belief- physician has information (thinks multiple physicians communicate with one another)
Unfamiliar with medications and names (generic/brand name (brand names easier to pronounce))
Difficulty remembering (drug effects, disease effects, dementia)
Language barriers (actual language or generational things)
Hearing impairment
Elderly clients
Caregiver administers or sets up medications
Medication vials or list unavailable
Inaccurate or incomplete patient records
OR getting medications at multiple pharmacies
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Interviewing the Client
```
Introduce yourself (Greet patient with Mr./Mrs. OR title)
Give purpose of interview
Inform client of importance of maintaining a current/accurate medication list in chart
```
26
Questions to ASK
1. Which community pharmacy do you use?
2. What type of prescription insurance do you have?
3. Any allergies or adverse effects to medications and what was the reaction?
(Medications didn't agree with you? What happened?)
4. Which medications are you currently taking:
-The name of the medication
-The dosage form and route (tablet, capsule, liquid)
-The amount (specifically the dose)
-Frequency of administration (scheduled or PRN)
-Any specific times or instructions? ('Statin at night)
-For what reason (if not known or obvious) (supplement, herbal)
-When did they start taking it?
-Is the drug working? (Symptom resolve?)
-Is the drug causing problems? (Constipation, diarrhea, nausea, weight loss)
5. Any other medications (regular or as needed basis)
-OTC medications
-Vitamins
-Herbal or complimentary medications
Specifically:
-Pain medication
-Aspirin
-Sleep aids
-Topical medication
-Inhalers
-Cough/cold medications
-Sinus/allergy medications
-Stomach medications/antacids
-Laxatives/antidiarrheals
-Ear/nose/eye medications
-Vitamins
-Injections
6. Tobacco:
-Do you use tobacco? Have you ever used tobacco?
-When did you quit? How much do/did you use? (Packs per day x number of years)?
7. Alcohol:
-Do you drink any alcohol? Have you ever used alcohol?
-When did you quit? How much do/did you drink? (Number of drinks per day/week/month/year)? What type of alcohol do/did you drink?
8. Caffeine:
-Do you drink caffeinated coffee/tea/soda?
9. Do you have a system for managing your medications?
-Pillbox or mediset
-Other organization system
-Calendars
-Help from caregivers
10. How often do you miss your medications? (Endorsing it's okay to miss your meds?
-Miss entire dose vs. taken late?
-How are missed doses handled
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Medication History Taking TIPS
Balance open-ended questions (what, how, when, why) with yes/no questions
Ask non-biased questions (don't judge)
Avoid leading questions (don't put words in their mouth; would get inaccurate response)
Explore vague responses (non-compliance)
Avoid medical jargon- keep it simple and direct (lay terms)
Avoid judgmental comments (simple or direct)
If medication vials available:
- Review each medication vial with patient
- Confirm contents of bottle
- Confirm instructions on prescription vials are current
- Check refill dates and pill counts (compliance)
* check with pharmacy; they may be pouring new vials into the old one due to specific markings*
If medication list available:
- Review each medication with patient
- Confirm that this is current
If bubble packs available:
- Review each medication with patient
- Confirm patient is taking according to schedule
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Additional Questions to Explore Effectiveness/Compliance
Are any of the medications causing problems (side effects)?
Have you changed the dose or stopped any medications because of unwanted effects? (Medication intolerance)
Do you sometimes stop taking your medicine whenever you feel better?
Do you sometimes stop taking your medicine if it makes you feel worse?
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Client Education
- Encourage ownership (patient to take charge)
- Educate client to bring medications from home at each appointment (including OTCs and supplements)
- Educate client to carry a list of current medications (prescription and OTC)
- Encourage family members/caregivers to become involved
- Encourage one pharmacy (all records in one place)
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Tools for Clients
```
Medication Lists
"Brown bag"
Pharmacy receipts
Discharge med instructions
Written documentation of changes
Personalized health record (surgeries, vaccinations, problems)
```
31
What is Medication Reconciliation?
-Comparing a patient’s medication orders to all of the
medications that the patient has been taking.
-Done to avoid errors such as omissions, duplications,
dosing errors, or drug interactions.
-Should be performed at every transition of care in
which new medications are ordered or existing
orders are rewritten. (Inpatient in hospital place for errors)
-Transitions include changes in setting, service,
practitioner, or level of care.
32
Factors Contributing to Medication Discrepancies
- Limited recall of discharge instructions (just want to get home)
- Problems with compliance (intentional vs. unintentional (remember vs. don't understand))
- Frequency of errors on discharge medication lists (omissions and duplications, incorrect or incomplete information) (ex. Ambien need to sleep in hospital because practitioners are coming in out of the room at all hours, but don't need at home)
- Problems with medication administration upon return home
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Reconciliation
Who? Pharmacist! (Provider or staff; nursing or MA)
When? Every office visit, transfer of care (provider or location)
How? Brown bag, home list, or institutional MAR
Medication list in chart
Patient interview
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The Medical Chart
1. Repository of information concerning a patient’s care
2. Primary mode of communication between healthcare
professionals
3. Tool for building the pharmacist’s patient database
4. Legal document (politically correct)
35
Confidentiality
1. Protect confidentiality and privacy
2. Information shared on a “need to know” basis (social work or psychiatry ("break the glass"))
Breach of confidentiality may result in:
1. Civil or criminal prosecution and penalties (Civil- lower burden of proof so if don't win in criminal case. Patient could sue not only health care provider, but their employer)
2. Scholastic or employment action corrective action which may lead
to dismissal, termination, or suspension/revocation of privileges
Reporting of known breach is required (Employee Relations)
36
HIPAA
Health Insurance Portability and Accountability Act
Protected health information (PHI):
1. Prescription records
2. Billing records
3. Patient profiles
4. Verbal or written communications regarding care
Information shared in “minimum necessary” manner
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Sharing HIPAA information:
Use professional judgement:
1. Permissible for friends/family to pick up medications
2. Permits limited sharing of info with family/caregivers, unless
patient requests otherwise
3. Allows announcement of name in waiting room/PA system
4. Allows reporting of abuse, public health concerns, law
enforcement, federal drug or device-related problems, workmen’s
compensation
Age of consent in NE is 19-years-old
Civil cases:
-Only submit information pursuant to subpoena
38
Chart Organizations: Sections
1. Admitting Data/Patient Info
2. Physician Orders
3. Graphic Charts and Flow Sheets (temp., weights, blood)
4. Nursing Notes (when IV was hung, turning patient, etc)
5. Laboratory Data
6. Diagnostic Procedures and Imaging (X-Ray)
7. OR Procedures
8. History & Physical
9. Progress Notes
10. Medication Administration Record
11. Consults (other services)
39
Chart Contents: Admitting Data
Biographical Data: Name, address, phone, DOB, sex, race, marital status, religious affiliation, emergency contact, employer, occupation (exposures), SSN
Financial Data: Guarantor (responsible party), insurance company, policy number, Medicare number
Admission Data: Date/time of admission, admitting MD, admitting diagnosis,
room/bed number, account or admission number
Consent Forms: Consent for treatment, tests, procedures, investigational therapy,release of information, photographs/tapes/films
40
Chart Contents: Physician Orders
1. Directives for patient care and treatment
2. Written by MD or other provider
3. May be verbal or telephone orders (taken by scribe) (nurse can put in and Dr. can consign within 24 hours)
4. Include date and or time
5. May be “standard” or preprinted order sets (myocardial infarct set-safety net)
6. Medication orders
-Drug, dose, route, frequency, special instructions, indication,
duration (if applicable)
41
Chart Contents: Graphic Charts/Flow Sheets
Records of monitoring activities arranged so that trends and
patterns are easy to visualize
-Vital signs (graphs)
-Intake/output
-IV fluids (volumes administered)
-Neurological checks (head injury-pupils & reflex)
-Blood sugars/insulin doses
42
Chart Contents: Nursing Notes
Nurses observations and patient care activities
- Physical functioning (pale, agitated)
- Behavioral/mental status
- Clinical signs and symptoms (pain, loose stools)
- Nursing interventions (IV given, med administration)
- Documentation of care
- Patient education
- Discharge Plans
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Chart Contents: Laboratory
Hematology
RBC, WBC, HGB, PLT, WBC differential
44
Chart Contents: Laboratory
Chemistry
Electrolytes (Na, K, Cl), Mg, Ca, cholesterol, AST, ALT, Scr, BUN, cardiac enzymes, TSH
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Chart Contents: Laboratory
Microbiology
Gram stains, cultures, sensitivities (test against different antibiotics)
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Chart Contents: Laboratory
Urinalysis
PH, osmolality, WBC, casts, bacteria, glucose
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Chart Contents: Laboratory
Blood Bank
Type and screen, cross match
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Chart Contents: Laboratory
Blood Gases
PH, O2, CO2
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Diagnostic Procedures/Imaging
Procedures:
```
Endoscopy (EGD)
Colonoscopy
Biopsy
Cystoscope
(invasive)
```
50
Diagnostic Procedures/Imaging
Radiology reports:
CAT Scan (CT)
Magnetic Resonance Imaging (MRI)
X-rays
Ultrasound (US)
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Diagnostic Procedures/Imaging
Cardiology/EC:
Electrocardiograph (ECG)
Doppler Ultrasound
ECHO
52
Contents: Consults
Consultation notes from various specialties:
1. Cardiology
2. Infectious Disease
3. Psychiatry
4. Neurology
5. Surgery, etc.
53
Chart Contents: OR Procedures
Operative reports
Anesthesia records
Post-anesthesia care
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Chart Contents: History & Physical
- Chief Complaint (CC)- "Exactly what brings the patient to the hospital or clinic in the patient's own words"
- History of Present Illness (HPI)- Chronological outline and details of the current medical condition
- Past Medical History (PMH)- Patient's other medical conditions (past and present), family history, social history, surgical history, and allergies
- Review of Systems (ROS)- Patient report of symptoms grouped according to organ system
- Physical Exam (PE)- Physical information and findings that support information provided in ROS grouped by organ system
- Admission Tests- Results of labs and diagnostic procedures
- Assessment and Plan (A/P)- Provider assessment or impression of patient's condition with working diagnosis and initial plan of therapy
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Chart Contents: Progress Notes
- Running commentary on patient's condition and treatment throughout the hospital stay or during each clinic visit
- Narrative or outline format
- Forward or reverse chronological order
- Documented in SOAP format
56
SOAP Note Format
1. Subjective- Information subject to individual interpretation (pain, nausea, fatigue, confusion, etc); perceived by individual only and not evident to examiner
2. Objective- Information based on replicable or quantifiable data; usually measurable and has a number value (temp, drug levels, urine output,, diagnostic test results, etc); viewed by examiner as they exist in unprejudiced manner
3. Assessment- Provider assessment or impression of patient's condition with working diagnosis
4. Plan- Plan for further evaluation and therapy
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Pharmacist Progress Notes
- Pharmacokinetic consults
- Drug information consults
- Pharmaceutical care plans (SOAP)
- Medication histories
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Medical Administration Record
- Tells drug, dose, route, date, and time of medication administration
- Other meds may be recorded elsewhere: CORE medications, IV fluids (without drugs), anesthesia and peri-operative medications
- Includes patient's allergies and ADEs
- BEST source of documentation that medication was administered, but errors are possible
- Electronic charting in EMR (with bar code scanning)
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Chart Contents: Miscellaneous
- Reports from EMTs or paramedics
- Outside records from other facilities
- ER reports
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Chart Review: Summary
- Chart is documentation of everything that happens regarding care of patient
- Chart serves as a resource for treatment planning and communication between providers
- Medical-legal document
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Definition: Electronic Health Records
The EHR is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting
The EHR automates and streamlines the clinician's workflow
-Ability to generate complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface- including evidence-based decision support, quality management, and outcomes reporting
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EHR Components
1. Health information/data
2. Electronic communication
3. Administrative reporting
4. Population health reporting
5. Order management
6. Result management (labs)
7. Decision support
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Goals of EHR
1. Improve quality
2. Improve safety
3. Improve integration of care
4. Improve accessibility and timeliness
5. Improve efficiency
6. Provide long-term cost savings
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EHR Implementation
2008: <2% of hospital systems had comprehensive EHR
2009: HITECH Act
-Financial incentive
-Meaningful use
2015 begin phasing out
-Penalties for not having in later stages
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Advantages of EHR
1. Possibility of improved quality, safety, and care coordination
2. Electronic claims submission
3. Improved efficiency and accessibility
4. Immediate and continuing information
5. Reminders, protocols, & pathways
6. Link to other databases
7. Outcomes data
8. Decreasing charting time?
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Access/HIPPA
- HIPPA rules apply to all EHR data
- Audit trail of access
- Accessing your own chart
- Caregivers
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CPOE and Clinical Decision Support
CPOE (Computerized Provider Order Entry)
CDS (Clinical Decision Support)
- Guidance on clinical decisions
- Dosing alerts
- Pre-populated order fields
- Mandatory fields (Hard Stops)
68
Disadvantages/Barriers of EHR use
1. Cost
2. Security/confidentiality
3. Workflow changes
4. Substantial learning curve
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Technology and Communication
Patient education
-Changes delivery
Email messaging
Patient's view their own chart/labs/etc.
Eye contact/body position
Connectivity
-Immunization registry (pharmacies)
-NEHII
70
The Patient Interview
- Purpose is to gather information used to identify drug-related problems
- Utilizes written history (chart) or interview document
- Adheres to structured or ordered sequence
- Conducted under constraints of time and place
71
Comprehensive vs. Limited Data Collection
```
Goal of the encounter
-Comprehensive vs. focused
Consider practice circumstances
-Acute vs. chronic care
Limited approach may be appropriate if patient is not able to fully cooperate or there are time constraints
```
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Preparation
Gather advance information (e.g. Chart)
- Avoid duplication
- Opportunity to find out about unfamiliar therapy or conditions prior to interview
- Identify communication barriers (e.g. Hearing, cognitive)
73
Interview Components:
| Environment
- Private
- Quiet and comfortable
- Clean and organized
- Open, unhurried, relaxed attitude
- Give your full attention (active listening)
- Avoid interruptions
- Sit nearby (18-48 inches)
- Sit at eye level (face to face or 90~ angle)
- Remove physical barriers
74
Interview Components:
| Approach
- Greeting, introduction, explanation
- Limit small talk
-Establish rapport
~Indicate genuine interest in patient's welfare
~Show respect (use proper names and titles)
~Demonstrate relaxed, confident attitude
~Professional appearance
- Direct questions to patient
- Record information from collateral sources
- Try to illicit "real" concerns
- Maintain objectivity
- Be sincere and honest
- Acknowledge patient-specific attitudes without judgement
- Maintain control of the interview
75
Open questions
- Generally elicit more information and keep the patient talking
- Allows patient to answer any way they wish
- Allows information to be presented from patient's perspective
- "Can you tell me what you would take if you had any pain?"
- "How have you been feeling since you started the new medication?"
- Most useful for beginning an interview, introducing a new sequence of questions, and switching to a new topic
76
Closed (direct) questions
- Used for very specific information or details
- Patient is passive and forced to answer from interviewer's perspective
- "Does the chest pain occur when you are resting?"
- "Did you take your blood pressure medication this morning?"
- Useful when time is limited
- Overuse may feel like interrogation (negative and impersonal)
- Overuse may limit information obtained and lead to inaccurate assessment
**Combination of open and closed questions is usually most effective**
77
Feedback: Faciliation
-Encouraging an interviewee to say more without directing the conversation
-Shows interest
-Verbal:
"Yes, go on.."
"Please continue..."
-Non-verbal:
Maintaining eye contact
Nodding affirmatively
78
Feedback: Attentive Silence
- Silence provides opportunity for interviewee to speak after taking time to think and organize what he/she wants to say
- Interruption of silence may destroy thought process
- Long pauses may also indicate that the patient is confused or embarrassed and the interviewer may need to repeat the question in a different manner
79
Feedback: Summation
- A review of what the patient has communicated
- A summary provides verbalization of what you have understood and allows the person to clarify certain points
- Can be used at any time or to conclude the interview
- Allows patient to disagree and correct pharmacists' interpretation if necessary
80
Forms of Nonverbal Communication
- Behavior: facial expressions, body posture (open), gestures, voice quality, eye contact, distance
- General demeanor
- Personal appearance
- Communicate interest: lean forward, maintain eye contact, voice inflection
81
Implications of Body Language
- Steepling of the hands: Confidence
- Raising the hand: Desire to interrupt
- Shifting body position: Desire to interrupt
- Crossed arms: Shutting the other person out
- Leaning toward the speaker: Receptiveness
- Raising hands, then letting them fall: Hopelessness
- Frequent throat clearing: Disagreement
82
Errors in Patient Communication
- Changing the subject
- Giving personal advice
- Providing false reassurance
- Using leading or biased questions
- Using professional medical terminology
- Avoid multiple questions
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Avoiding Bias
Bias introduced when interviewer suggests the expected or acceptable answer via the working of the question or non-verbal communication
- Avoid adding "or not" to end of question
- Avoid providing several potential answers
- Avoid emotionally charged words
- Avoid "why" questions
84
Adjusting for Interviewee Characteristics
Family Background: Role in family (wage-earner, etc.), family dynamics may influence reporting, look for verbal/non-verbal cues
Cultural Background: May effect reporting style (stoic vs. vocal) and interpretation of information, language barriers may be present, avoid medical jargon
Socioeconomic Background: Social distance may undermine trust and quantity/accuracy of information, may influence terminology, compliance, tendency toward self-care
Age and Gender: Men and elderly less likely to report symptoms, elderly may respond slower (avoid hurrying, interrupting, or finishing sentences)
85
Special Situations
Embarrassing issues
- E.g. Sexual dysfunction, birth control products, drug or substance abuse, obesity, illiteracy, incontinence, non-adherence
- Be aware of potentially embarrassing situations and be prepared to bring up the subject
- Be respectful and maintain private environment
- Use straightforward language and anatomically correct terms
- Avoid humor
86
Special Situations
Elderly patients
- E.g. Limited hearing and vision, respect issues
- Speak slowly, distinctly, and directly to patient
- Avoid youth oriented slang
- Do not assume impaired hearing
- Use large print materials
- Reinforce with verbal communication
87
Special Situations
Mute patients
- E.g. Endotracheal tubes, tracheotomy, damage to vocal cords, hearing impairment
- Written communication
- Point- and spell letter boards
- Allow sufficient time for communication
- Maintain your end of the conversation and do not limit verbal responses just because patient cannot speak
88
Special Situations
Hearing impaired patients
- Do not assume diminished intellectual abilities
- Do not assume patient can read lips
- Do not assume normal hearing with hearing aids
- Training (e.g. Sign language) is helpful
- Communication should be slow and distinct
- Minimize background noise
- Directly face patients who can lip read
- Written communication may be necessary
89
Special Situations
Physically challenged patients
- Avoid assuming link to mental disabilities
- Be aware of speech, vision, or hearing impairment
- Engage patient in unhurried conversation with ample time to respond
- Speak directly to patient
- Do not provide physical assistance unless requested
- Maintain appropriate level of eye contact
90
Special Situations
Mentally challenged patients
- Communicate directly and clearly with patient and caregiver
- Do not assume patients are incapable of participation
- Appropriately assess level of patient participation
91
Special Situations
Pediatric patients
- Communicate with patient as well as parent/guardian
- Provide information that is appropriate for the child
92
Special Situations
Critically ill patients
- Patients lack privacy and control; may be overwhelmed
- May be in pain due to illness or procedures or drowsy from pain medication
- Communicate directly and acknowledge them with eye contact (if possible) and by speaking when entering or leaving room/bedside
- Also communicate with family
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Special Situations
Chronically/terminally ill patients
- May be sophisticated health care consumers or extremely demanding
- May be bitter, cynical, hopeless, and difficult to engage
- Adjust communication to meet patient needs
- May need to work with patient to legitimize use of narcotics due to fear of addiction
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Special Situations
Hard to reach patients (poor access)
- E.g. Low socioeconomic status, minorities, illiterate
- Few resources (social and financial) to deal with healthcare and preventative care issues
- Poor health literacy
- Treat each patient as individual, regardless of status
- Be prepared to meet greater health needs
- Organization of complex medication regimens
- Calendars, pill boxes, and other delivery devices
- Suggesting alternate, less expensive medications
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Special Situations
Antagonistic patients
- May not want to be bothered with medications histories or counseling
- May need more attention due to alienating behavior
- Avoid natural response to leave them alone
- Be professional, direct, and respectful
- Limit interaction to as short a period as possible
- Clarification of purpose of information may be helpful
