introduction Flashcards
(32 cards)
Area of pharmacy concerned with the science and practice of rational medication use
● Health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness and disease prevention
Clinical Pharmacy
Responsible provision of medication related care for the purpose of achieving definite outcomes that improve a patient’s quality of life.
● We are also responsible in suggesting non-pharmacological treatments to the patients
Pharmaceutical care
goals of pharmaceutical care
a. Identifying
b. Preventing
c. Resolves medication related problem
Key elements of pharmaceutical care
Assessment – assess the patient complaint. Most patient with cough. (Ex: Ask the patient if the cough is dry cough or with phlegm and how long they experience the cough) Clear phlegm – Cause by viral infection. Viral infection is self-limiting (in tagalog: kusang nawawala). - You can recommend to patient who experience clear phlegm to eat more fruits, increase water intake and take vitamin c to boost immune system. Phlegm with color – Cause by bacterial origin - Ask the patient if the phlegm is sticky (give mucolytic to melt the phlegm ex. Solmux and Acetylcysteine) and malabnaw (give patient expectorant). But advise the patient to consult to physician for further assessment.
b. Care plan- make a plan for the patient complaint
c. Evaluation- to make sure that the plan works and have good outcome
●3 Hospital institutions with established clinical pharmacy practice
St. Luke’s, Cardinal santos, and Medical city
1 community pharmacy with clinical pharmacy service
Mercury Drug Store
Contains all pertinent information which enables the doctor or any medical practitioner to deliver effective continuing care to the patient.
● Made accessible to all health care providers that attend to the patients care needs
The medical chart
Importance/Purpose
- Planning and continuous care for the patient
- Means of communication between the physicians and other health care providers who contribute to care of the patient
- Supporting evidence that reflects the course of the patient illness and treatment during hospitalization
- Protection of the legal interest of the patient, the health instructions and all responsible practitioners
- Research and education- We can visualize what happens to the patient when we administer an investigational drug.
Ex. Empagliflozin is for diabetes and now it is tested for heart failure
Name, birthday, age, and gender
● Educational background and work
identification and sociological data
Involves data obtained about the patient’s previous illness or medical conditions/ therapies, family occurrences with illness, and relevant patient activities
personal family history
date of onset
● precise location
● nature of onset, severity and duration
● presence of exacerbations and remissions
● effect of any treatment given
● relationship to other symptoms, bodily functions, or activities (e.g., activity meals)
● degree of interference with daily activities
history of present illness
gen (genital appearance)
● VS (vital signs)-blood pressure, pulse, respiratory rate, and temperature
● Skin
● HEENT (Head, eyes, ears, nose, and throat)
● Lungs/ Thorax (Pulmonary) ● Cor or CV (Cardiovascular) ● Abd (abdomen)
● Genit/rect (genitalia/rectal) ● MS/Ext (musculoskeletal and extremities)
● Neuro (neurologic)
Physical examination
Provide to the healthcare team regarding medications, procedures, treatments, therapy, diagnostic tests laboratory.
●Hand written
● Doctor’s directions for its paramedicals or other healthcare professionals
physician’s order sheet
Gross and microscopic pathological findings
● Print out Xray and lab results
Laboratory tests, XRAY results, and ultrasound results
Means that your doctor is not 100% sure of a diagnosis because more information is needed
● Only possibility; Upon further investigation; Candidate diagnosis
● t/c meaning to consider
Provisional or working diagnosis
●A brief summary of hospitalized Pt’s current clinical status, written sequentially in the chart, reflecting information provided by physical exam, lab tests, and imaging modalities.
● Military time
Progress notes
Medical note into a medical or health record made by a nurse that can provide an accurate reflection of nursing assessments, changes in patient conditions, care provided and relevant information to support the clinical team to deliver excellent care.
NURSE’S NOTES
Chart is used to document a patient’s fluid input and output within a 24-hour period.
FLUID INPUT AND OUTPUT
This where you can see what are IV fluids given to the patients with their flow rate
IV FLOW SHEET
Used to document medications taken by each individual.
MEDICATION ADMINISTRATION RECORD
This form is a legal document that shows your participation in the decision and your agreement to have the procedure done. When you sign the form, it means: You received all the relevant information about your procedure from your healthcare provider
CONSENT FORMS FOR PROCEDURES
Identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination and review of laboratory data.
FINAL DIAGNOSIS
Condition on discharge
Follow up notes
Autopsy reports
MISCELLANEOUS
he primary purpose is to convey information for use in patient care and serves as a tool for communication among health care providers • Serve as record of the data collected, critical thinking and judgment used in identifying and addressing DRPs identified.
Why do you need to Document?
