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TREATMENT CHART REVIEW
The term ‘medication review’ does not have a single well-defined meaning and is often found to include a wide range of interventions, from technical prescription review over interventions aimed at patient compliance to comprehensive medication management strategies. In studies of the effect of medication reviews, the tools used to perform the actual ‘medication reviews’ are vaguely often described or not described at all. A few validated tools to support medication reviews have been developed, such as the STOPP & START-criteria by Gallagher et al. or the Medication Appropriateness Index (MAI) by Hanlon et al. The process of performing a medication review should, however, not only be a one-track search for inappropriate use of selected high-risk drugs, a reconciliation of medicine lists, or a search for cost- savings. Rather, a full medication review should ensure that all drugs on a patient’s list of medication are assessed, and that every diagnosis is treated according to guidelines, e.g. taking comorbidity and specific patient characteristics into consideration. While such considerations may be expressed on a general level, detailed descriptions and procedures for medication review is lacking. Such procedures should clearly outline how to conduct a medication review, among other things taking into consideration the setting, as the data sources differ widely between e.g. a pharmacy and hospital setting. No single procedure will ever be universally accepted as a gold standard or a one-size-fits-all solution, nor should it be. A discussion of the procedures used by clinical pharmacists is, however, important in order to ensure a continuous development of the quality of the pharmaceutical services offered to patients. This paper describes a practice model for pharmacist’s medication review, tailored to the general practice setting. The model includes Collaboration with the general practitioner (GP) but does not include a patient interview, and was tested in a pilot study by conducting medication reviews on Poly pharmacy patients i.e. receiving 7 or more drugs for regular use.
METHODS
The method is divided into seven main steps. The first three steps focus on collecting information about the patient, while the fourth and fifth steps identify drug- related problems. The sixth and seventh steps concern the reporting of interventions and the GP’s consideration. The overall focus of the method is the patient and the patient’s diagnoses as a whole. As such, the model can be regarded as patient- centered, as opposed to methods focusing on the single drug/prescription. A patient interview is not part of the model. COLLECTING INFORMATION (STEP 1-3) The first step of the model was to read the last year of the patient’s electronic health records, i.e. the medical chart, often including information on lifestyle factors such as smoking or alcohol use and information on drug allergies, along with clinical and laboratory data. The medical chart is specific for the GP and only information known by the GP can be found in the system. If one year contained less than 20 entries, the latest 20 entries were read instead. Medical charts were always read chronologically. The patient’s initials, birthday, most recently measured blood pressure (BP) and estimated glomerular filtration rate (GFR) were registered along with all registered diagnoses that would be expected to require a pharmacological treatment. In the second step, the current pharmacological regimen was retrieved from the GP’s lists of established prescription drugs along with their respective indication for treatment. In the third step, the list of diagnoses was reconciled with the list of the current pharmacological treatment. This was accomplished by deciding whether the presence of each drug was accounted for by one of the diagnoses. For each patient, a list of the drugs that did not match a corresponding diagnosis was compiled. To reduce the risk of the pharmacist intervening towards well indicated treatment, the patient’s medical chart and discharge summaries were then re-read, this time looking back five years starting with the oldest entry. Note that this was only done if one or more drugs had no apparent indication. Diagnoses identified in this way were added to the list of diagnoses. IDENTIFICATION OF INTERVENTIONS (STEP 4-5) The fourth step focused on the diagnoses. First, treatment goals were set for each diagnosis using guidelines for the individual disease, e.g. target HbA1c-levels for
a cost-saving of a minimum of 5.0DKK (corresponds to approximately 0.6EUR) per day with no loss of efficacy, it was suggested to change to another drug. If it were possible to reduce the number of daily dosages, it was suggested to change dosageregimen or change to another drug. Each intervention was substantiated by a shortaccount of the relevance of this particular intervention for this particular patient, i.e. the intervention always included patient-specific information. The intervention furthermore included a reference to the relevant treatment guideline and a detailed description of how the GP should act, e.g. the appropriate way to discontinue current treatment or initiate new treatment. All comments and proposed interventions regarding the patient’s medical treatment were registered in a single document. In the seventh and final step, the GP was asked to consider the findings of the pharmacist and to indicate whether or not each intervention was accepted. In cases where the GP chose not to follow the suggestions made, the GP was asked to provide the reason for not doing so. Finally, a copy of all interventions suggested by the pharmacist, together with the GP’s responses, was inserted into the patient’s medical chart for future reference.
MEDICATION HISTORY INTERVIEW
A medication history is a detailed, accurate and complete account of all prescribed and non-prescribed medications that a patient had taken or is currently taking prior to a newly initiated institutionalized or ambulatory care.
It provides valuable insights into patients’ allergic tendencies, adherence to pharmacological and nonpharmacological treatments, social drug use and probable self-medication with complementary and alternative medicines.
Interviewing a patient in collecting the data medical history is called medication history interview.
GOALS
The goal of medication history interview is to obtain information on aspects of drug use that may assist in over all care of patient. The information gathered can be utilized to: ‰Compare medication profiles with the medication administration record and investigate the discrepancies. ‰ Verify medication history taken by other staffs and provide additional information where appropriate. ‰ Document allergies and adverse reactions. ‰ Screen for drug interactions. ‰ Assess patient medication compliance. Assess the rationale for drug prescribed. ‰ Assess the evidence of drug abuse. ‰ Appraise the drug administration techniques. Examine the needs for medication aids. Document patient initiated medication administration. Importance of accurate drug history Medication histories are important in preventing prescription errors and consequent risks to patients.
INTERVIEWING THE CLIENT
- Introduce yourself
- Inform client of reason for you being there
- Inform client of importance of maintaining a current medication list in chart
Information sources
- Patient
- Family or Caregiver
- Medication Vials / Bubblepacks
- Medication List
- Community Pharmacy
- Medication Profile from other facility
- DPIN (Drug Programs Information Network)
Question to ask
- Which community pharmacy do you use?
- Any allergies to medications and what was the reaction?
- Which medications are you currently taking:
- The name of the medication
- The dosage form
- The amount (specifically the dose)
- How are they taking it (by which route)
- How many times a day
- Any specific times
- For what reason (if not known or obvious)
- What prescription medications are you taking on a regular or as needed basis?
- What over-the-counter (non-prescription) medications are you taking on a regular or as needed basis?
- What herbal or natural medicines are you taking on a regular or as needed basis?
- What vitamins or other supplements are you taking?
Medication History Taking TIPS
- Balance open-ended questions (what, how, why, when) with yes/no questions
- Ask non-biased questions
- Avoid leading questions
- Explore vague responses (non-compliance)
- Avoid medical jargon – Keep it simple
- Avoid judgmental comments
- Various approaches can be used:
- 24 hours survey (morning, lunch, supper, bedtime)
- Review of Systems (head to toe review)
- Link to prescribers (family physician, specialists)
- If medication vials available:
- Review each medication vials with patient
- Confirm content of bottle
- Confirm instructions on prescription vials are current
- If medication list available:
- Review each medication with patient
- Confirm that it is current
- If bubble packs available:
- Review each medication with patient
- Confirm patient is taking entire contents
- Have you recently started any new medications?
PATIENT COUNSELLING
DEFNITION
Patient counselling may be defined as providing medication information orally or in written form to the patients or their representative or providing proper directions of use, advice on side effects, storage, diet and life style modifications.
GOAL
To provide information directed at encouraging safe & appropriate use of medication, thereby enhancing therapeutic outcomes.
FUNCTION
Better patient understanding of their illness & the role of medications in its Improved medication adherer More effective drug treatment Reduced incidence of adverse effects & unnecessary health care costs Improved quality of life for the patient Better coping strategies to deal with medication related adverse effects Improved professional rapport between the patient & pharmacist
BARRIERS
Lack of time Lack of knowledge about drugs & patient's history Lack of confidence Poor communication skills Language barriers. Lack of awareness by the patient of the need for counseling & its availability Physical barriers Economic considerations & Poor patient perception of the pharmacist Administrative barriers
Negative attitude Poor patient perception of the pharmacist
COMMUNICATION
Communication is the transfer of information meaningful to those involved.It is the process in which messages are generated and sent by one person and received andtranslated by another person. Empathy : It is the ability to see & feel what the world is like for another person. Counseling process uses following :
- Verbal communication. Language Tone Volume Speed
- Non-verbal communication. Proximity Eye contact Facial expression
TECNIQUES OF COUNSELLING
StageI : Medication information transfer, during which there is a monologue by thepharmacist providing basic, brief information about the safe and proper use of medicine. StageII : Medication information exchange, during which the pharmcists answers questions and provides detailed information adapted to the patients' situation. StageIII : Medication education, during which the pharmacist provides comprehensive information regarding the proper use of medicines in a collaborative, interactive learning experience StageIV : Medication counseling, during which the pharmacist and patient have a detailed discussion intending to give the patient guidance that enhances problem- solving skills andassists with proper management of medical conditions and effective use of medication.
Ask the patient if they have any questions Document the interaction
STEPS OF BECOMING A COUNSELLING PHARMACIST
Evaluate your own values & priorities Evaluate barriers to patient counseling Arrange for removal or reduction of barriers where possible Arrange for counseling aids Prepare staff, physician & patients Prepare for each counseling session Progress into counseling insteps Remember to tailor counseling Arrange for practice. Self-evaluation
PATIENT COUNSELLING
AIM
To counsel the patient about disease , drug , lifestyle modification in Angina.
ABOUT DISEASE
- Angina is the cardiovascular disease in which chest pain Is produced.
- Blockage of blood vessel cause reduced blood supply to heart , lead to chest pain.
- Keep GTN bedside for immediate administration.
ABOUT DRUGS
- Do not skip the dose.
- If you forgot the dose, take when you remember.
- Do not take multiple dose.
ASPIRIN
- Aspirin should take at afternoon , because action is high.
- Aspirin should be take after food ,because it produces stomach irritation.
STATINS
- Statins should be take at night , cholestrol synthesising enzymes are more active at night.
NITROGLYCERIN
- GTN sublingual drugs donot be swallow , place below tongue for better absorption.
- Nitroglycerin must be kept in a dark container,away from heat and moisture.
- Once the container is opened , it must be discarded after 3 months.
- It should be taken 5 min before physical activity.
PATIENT COUNSELLING
AIM
To counsel the patient about medication , routes of administration , diet and life style modification in COPD
DISEASE BASED
Chronic obstructive pulmonary disease is the disease affecting lung. Due to inflammation of lung breathlessness is produced. Other symptoms are cough , wheezing ,mucus expectoration.
DRUG BASED
- A metered-dose inhaler (MDI) usually requires the patient to breathe in slowly and deeply. Most MDIs require priming and shaking before use.
- A dry-powder inhaler (DPI) requires a quick and deep inhalation to pull the powdered medicine into the lungs. DPIs should not be shaken.
- Clean the inhaler mouthpiece.
- Oder the new inhaler before exhausting of currently using inhaler
•Patients should discard any remaining medications past the expiration date.
- Store the inhaler at room temperature. Do not leave the inhaler where it might get too hot or too cold.
- Bronchodilators relax and open the airways in the lungs. Always use the bronchodilator first before using a steroid inhaler. Steroid inhalers decrease swelling in the airways of the lungs. Rinse out the mouth with water and then spit it out after using the steroid inhaler , therwise mouth ulcer is produced.
LIFESTYLE MODIFICATION
Stop smoking Take vaccination every year to get protection pneumonia. Eat a well-balanced diet and maintain your ideal body weight. excersise to help you build strength and breathe easier. Get emotional support. Living with COPD may cause fear, anxiety, depression or stress, Monitor air quality. Try to avoid dust and fumes, and stay indoors on bad air days. Check daily air quality levels and air pollution forecasts in your area. Stay away from dust , smoke ,other allergents.
Step 7: Conduct follow up and documentation
Stepl:Secure demographic of requester
The requester name, position, training of anticipated knowledge is important to determine the final response toquestion
Step 2: Obtain background question
The background question should be specific for the nature of the requester. Sufficient background information must be obtained in a limited time period
Step3:Determine and categorise the ultimate question
Adequate background information is needed to determine the ultimate question. There after the question should be categorized, as it will I help in developing the search
Strategy
Step4: Develop search strategy and conduct search
The information resource are selected based on probability of containing the desired information or data
|Step5: Perform evaluation, analysis and synthesis
The information must be analyzed and synthesized with considerations of the background information obtained previously. Analysis and synthesis together exist informing opinion arriving at judgment
Step 6: Formulate and provide response
Patient factors, disease, medication history etc. should be considered. The way in which answer are communicated plays a major role in determining how drug information is accepted by physician
Step 7: Conduct follow up and documentation
Follow up is the process of verifying the appropriate,correctness and completion of a response after it has been given
DRUG INEORMATION RESOURCES
PRIMARY SOURCES:
Research studies or clinical experience which has not been previously published. Provide the most current/ up to date information. Includes the researchers and manufactures materials such as patents and the data submitted to the medicines commission.
Primary source journals
American Journal of Therapeutics Annals of Internal Medicine Australian Journal of Hospital Pharmacy British Medical Journal New England Journal of Medicine
SECONDARY SOURCES:
Indexing and abstracting/summarizing the information previously appeared in
aprimary source
Abstracting services provide interpretations of the work done.
Valuable tools for quick and selective screening of the primary literature for specific
information, data, citation and articles.
Abstract types include: telephonic, indicative and informative
TERTIARY SOURCES:
Review articles and text books Articles provide two types of information's.
- General overviews
- meta-analyses
Text books provide concise, convenient and easy access to a broad spectrum of related topics Background information on drugs and diseases available
