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Patient  Assessment And  Clinical  Interviewing

Patient Assessment And Clinical Interviewing






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    Patient  Assessment And  Clinical  Interviewing Patient Assessment And Clinical Interviewing Presentation Transcript

    • Patient Assessment and Clinical Interviewing
    • Common Communication Mistakes Health Care Practitioners Make From: “Lessons from medicine and nursing for pharmacist-patient communication”, Am Jour of Health System Pharmacists, Vol. 53, June 1996, pages 1306-14.
    • Common Mistakes:
      • Failure to greet patients, tell them who you are and the purpose of your interaction with them.
      • Failure to find out what is bothering the patient – worries, concerns, issues – how the patient feels about their condition.
      • Accepting vague information too easily and not probing to find out more specifics.
      • Failure to verify that what you thought you heard, was what the patient really meant…
      • Failure to encourage patient questions.
      • Failure to be responsive to patient questions.
    • Common Mistakes:
      • Not paying attention to the verbal and NON-verbal communication messages sent by patients.
      • Avoiding information that is personal.
      • Using too many closed ended questions.
      • Allowing interruptions.
      • Drawing conclusions too soon.
      • Failure to provide appropriate information in the form of counseling.
      • Not understanding the patients viewpoint.
      • Poor reassurance.
    • Cultural Issues “ Home Remedies?”
    • Sample questions to explore cultural beliefs about health, illness and treatment:
      • What do you think caused your problem?
      • When /why do you think it started when it did?
      • How bad is your sickness?
      • What do you think should be done to get rid of this sickness?
      • How have you treated this illness?
      • What worries you about this sickness?
      • Do you think your treatment will help?
    • Recommendations to Enhance Cultural Sensitivity
      • First, all your communication skills from the tool box still apply.
      • Recognize that cultural diversity exists.
      • Accept that new to you can be stressful to you.
      • Know your own culturally derived preferences and values.
      • Rely on your rapport!
    • Recommendations to Enhance Cultural Sensitivity
      • Listen and attend to verbal and non-verbal cues that could provide information to you.
      • Remember that YOU might be facing something completely new to your belief system.
      • Develop a genuine acceptance, respect and tolerance for your patient’s cultural values.
    • Recommendations to Enhance Cultural Sensitivity
      • Acknowledge that you don’t know everything and ask your patients to explain the things you don’t understand.
      • Stephen Covey: “seek first to understand”.
      • Do not label or judge customs, norms, or habits your patients present.
      • Approach cross cultural situations with a willingness to explore your patient’s world.
      • Meet and develop rapport with members of other cultures.!
    • When will I need patient assessment or clinical interviewing skills?
    • The Pharmacy Care Process Collect and use patient information Identify patients’ drug related problems Develop solutions to these problems Select and recommend therapies Follow up to assess patient outcomes
    • When will I need patient assessment or clinical interviewing skills?
      • Patient counseling
      • Examining patients
      • Making OTC recommendations
      • Many other situations:
        • hospitals, long term care
        • Ambulatory clinics such as anticoagulation, other disease management efforts, HTN, diabetes, asthma, flu shot clinics, collaborative practices with physicians and other providers
    • We want to differentiate assessment and interviewing from counseling – but the same skills apply. One of the primary differences is documentation.
    • Questions asked in the background of the pharmacists mind while conducting patient assessment activities:
    • Patient Assessment Questions:
      • Are any of the patient’s complaints or abnormal objective/physical findings related to drug therapy?
      • What are some other possible causes of the patient’s complaints / symptoms?
      • Are each of this patient’s medications appropriately prescribed?
    • Patient Assessment Questions:
      • Is each medication the best one for this patient to be taking? Safest, most effective?
      • Is this the right dose given the patient specific information (severity, size, gender, etc.)
      • Is the patient having any apparent drug related side effects?
    • Patient Assessment Questions:
      • Are any possible drug interactions present?
      • Is this patient able to follow this drug regimen?
        • Does the patient know how to use this medication correctly?
      • Is additional medication needed to resolve the patient’s complaint / symptom?
    • Documentation
      • Provides a permanent record of patient information.
      • Provides a record and evidence of pharmacy care provided.
      • Communicates to other practitioners what you have done.
      • Provides a legal record of what you have done.
      • Provides documentation for billing purposes.
    • Documentation
      • Legally, “…if it isn’t documented it wasn’t done…”
      • From a billing perspective, each CPT Evaluation and Management Code requires certain information be recorded in the chart.
      • 99211; very basic, 5 minutes or less. Requires only 1 vital, date, provider, problem addressed.
    • The SOAP Note
      • Subjective – complaints, symptoms, recent history, past medical history, medication history, allergies, social and family history, review of systems.
      • Objective – vital signs, physical findings from examination, labs tests, blood levels of drugs, medication profile.
      • Assessment – critical thinking and analysis of the problem.
      • Plan – actions to be taken.
    • Problem Oriented Note
      • Generate a list of patient problems and provide a SOAP note for each problem (or closely related problems.)
      • Be consistent.
      • When no drug therapy problems are noted, state this.
    • General Types of Data to Collect in a Clinical Interview
      • Name, address, phone, fax, email, etc.
      • Height and weight (physical assessment).
      • Primary physician, specialists, dentists, addresses and phones if possible.
      • Insurance information (copy of card if possible).
      • Rx and OTC medication lists.
      • Herbal supplements, vitamins, and any other substances used.
    • General Types of Data to Collect in a Clinical Interview
      • Medical problem list, including date diagnosed, surgeries, hospitalizations, etc.
      • Pregnancy, lactation.
      • Alcohol and tobacco use.
      • Labs, if available.
      • Special monitoring that the patient performs.
    • General Types of Data to Collect in a Clinical Interview
      • Possible compliance barriers.
      • Any patient concerns or questions
      • Name and title of person collecting the information.
    • Specific Data Needed:
      • Chief Complaint
        • A brief statement of why the patient is seeking care.
        • 1-2 primary symptoms with their duration.
        • Recorded in the patient’s own words.
        • Remember, patient’s may not always have a CC: they may present with a problem they do not know is drug related.
    • Specific Data Needed:
      • History of present illness
        • Timing, onset, duration and frequency of Sx.
        • Location
        • Quality (sharp, dull, ache, red blood, tarry stools)
        • Quantity or severity of Sx (mild, moderate, severe)
        • Setting: when do the Sx occur?
        • Aggravating or relieving factors
        • Associated symptoms (other Sx that occur in conjunction with the primary Sx)
    • Specific Data Needed:
      • Past Medical History
        • List of past problems, related or not to the CC
      • Family History
        • Presence or absence of illness in the immediate family (living or dead, illnesses
        • F 67 (CVA)
      • Social History
        • ETOH, tobacco, exercise, etc.
    • Specific Data Needed:
      • Review of Systems
        • General health
        • Skin, hair and nails
        • Eyes, ears, nose and throat
        • Head and neck
        • Respiratory system
        • Cardiovascular
        • Gastrointestinal
    • Specific Data Needed:
      • Review of Systems
        • Hepatic / Renal
        • Musculoskeletal
        • Nervous system
        • Mental status
        • Endocrine system (diabetes and thyroid)
        • Male reproductive system
        • Female reproductive system