patient centered care worksheet

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PynverZnevr2294

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Use the power point attached and make up a fake patient scenario of your own going over how you would talk to a patient and make a recommendation. Please use the form attached

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Self-Care Patient Encounter Worksheet Subjective Data Patient Demographics: Gender: ___F_____ Age (not Date of Birth): 55 What was the patient’s chief complaint? History of Present Illness (HPI) PQRSTA • Document areas applicable to patient complaint Precipitating: Palliative: Quality: Radiation: Site: Severity: Temporal Associate Symptoms/ROS Past Medical History • What medical conditions did the patient report? Family History • What conditions exist in the patient’s family that may affect their risks for medication conditions or affect their treatment plan? Social History • Only ask for information if needed to make the OTC recommendation or referral Did the patient smoke or chew tobacco? Yes No If yes, how much? ___________________________ Did you ask if they were willing to quit? Yes Did the patient drink alcohol? Yes No No If yes, in what form and how much? ___________________________ Did the patient drink caffeine? Yes No If yes, how much? ___________________________ Was the patient pregnant or breastfeeding? Yes No Objective General Observations How did the patient look? (distress, comparison to stated age, skin coloration, hygiene) Vitals • • Reported temperature if fever mentioned in chief complaint Obtain additional vitals as needed for patient’s chief complaint Temp: HR: RR: BP: Ht: Wt: Medication History • • • What prescription, non-prescription, herbals and/or vitamins does the patient take? o Include name (brand/generic), strength, dose, directions, indication, length of therapy Has the patient missed any doses or did they have problems with their medications? o Assess the patient’s adherence and explore barriers to adherence Document how the patient says they are actually taking the medication and not just what is written on the bottle. Medication Name & Dose How is it being taken? What is it treating? Notes Allergies/Adverse Drug Reactions • • Did the patient have any allergies or adverse reactions to medications? If so, what medication and what was the reaction? Medication/Allergen Description of Reaction (Allergic Reaction or Adverse Event) Immunizations • • What immunizations has the patient had? Are they due for any immunizations? (always check updated immunization schedules on CDC.gov) Immunization Type Date(s) Assessment Summary • • Differentiate patient’s signs/symptoms and identify the patient’s primary problem Determine if the patient’s problem(s) are controlled or uncontrolled and the appropriate level of care for each problem Step 1 Step 2 Step 3 Step 4-6 Step 7 Step 8 Step 9 Problem # __: What S&O evidence supports your assessment of the problem? Treatment goals: Controlled or Uncontrolled: What medication related problems are associated with this problem? What patient factors need to be considered when treating this problem? (medication cost, beliefs, etc) Does the patient need to be referred to another HCP? If so, who? What immunizations or preventative care recommendations should be made related to this problem? Copy additional tables as needed for each problem. Plan of Care/Implementation • • • • Consider all therapeutic options What pharmacologic and/or non-pharmacologic therapies did you recommend? What is your justification for the recommended therapies? (usually only included in academic notes) o Cite references What did you suggest in terms of follow up and monitoring (labs, symptoms, vitals, adverse reactions)? o Remember to include what the patient should monitor for signs of improvement or when to seek additional help (ex. temperature, improved pain, decrease in allergy symptoms, etc.). Plan Implement Problem #__: Patient-Specific Goals: Medication Recommendation: Patient Monitoring: Provider Monitoring: Referral to other HCPs: Follow-up: Justification/Citation: Follow-up: Patient Education/Nonpharmacologic Therapy: Medication Counseling Copy additional tables as needed for each problem. Applying the JCPP Patient Care Process Lab: Collection Michael A. Biddle, Jr., Pharm.D., BCPS Objectives (Lecture) • Identify examples of the attitude and skills that should be incorporated into all patient encounters • Identify and describe the components of a patient interview • List the components of and formulate questions for an HPI (PPQRSSTA) Objectives (Lab) • Identify pertinent subjective and objective information needed to identify and address a patient’s problem(s) • Develop questions that utilize appropriate communication skills to collect pertinent subjective and objective information from a patient Communication Skills Our “Baggage” • Mindset • Your state of mind/attitude that influences your encounter • Prejudices • Preconceived attitude, opinion or feeling about a patient • Treat every patient like the first patient of your day • Leave your emotions and problems at the door • Always be patient centered!! Attitude & Skills • Attitude • Respect • Empathy • Professionalism • Skills • Verbal Skills • Listening Skills • Educational & Instructional Skills Respect • Begin each encounter with a clean slate (unbiased) • Leave all of your baggage (mindset & prejudices) at the door • Be polite • Introduce yourself • Address the patient by their last name unless told otherwise by the patient • Address the patient directly • Especially important if there is a caregiver present • Respect differences in culture and background • Respect the patient’s right to choose • Your job is to help the patient, not save them Empathy • Demonstrate compassion and empathy • Acknowledge a patient’s current life situation • Recognize how a condition impact’s a patient’s quality of life • Never say: “I understand how you feel” – sympathy • Make appropriate eye contact and use appropriate responses • Listen - move beyond just hearing the patient • Demonstrate investment of time and concern • Go beyond your job description Professionalism • Dress professionally • Be confident but not egotistical • Assure and preserve confidentiality • HIPPA • Adhere to high ethical standards • Avoid behaviors that you would not want patients to emulate Verbal Skills • Speak clearly with appropriate volume • Patients with hearing loss – Lower your pitch • Speak at the patient's level of education • Avoid medical terminology • Begin with open-ended questions and move to closed-ended questions when needed • Redirect patients when conversations drift • Never abandon a line of questioning Listening Skills • Observe the patient for non-verbal cues • Be aware of your own non-verbal cues • Encourage patient story telling • Collaborate with the patient and gauge their responses when developing a treatment plan • Recognize signs that indicate a patient is not engaged • Listen to the patient!!! • Avoid asking questions that were already answered Patient Educational Skills • Be aware of the patient’s level of health literacy • Understand how a patient’s beliefs, culture and socioeconomic status may impact their condition and treatment plan • Include the patient in the development of the treatment plan • Have the patient repeat back the plan to assure understanding Collection: History Taking for Pharmacists Patient Data Collection • Symptoms (Sx) • Subjective information • Physical complaints or psychological feelings the patient experiences and DESCRIBES TO YOU • Signs (S) • Objective information • The physical or mental manifestations you discover by physical examination, labs, imaging, tests, etc. Patient Interview • Goals: • Identify the problem • Gather enough information to make an appropriate plan for the patient • How we obtain subjective information • Information the patient says about themselves • Main source for patient information in most settings • Chief Complaint/Focused History • Patient’s history as it relates to their chief complaint • Most commonly used by pharmacists • Comprehensive History • Used by diagnostic providers • Rarely used by pharmacists How do you introduce yourself? • Always introduce yourself first • • • • Name Title (advocate for your profession!) Who you are working with (if applicable) Reason you are talking to them • Identify the patient • Name • DOB • Refer to the patient by last name • Mr. Smith, Ms. Jones, Dr. Doe • Start with a general, open-ended question • How can I help you? • What brings you in today? What do you gather? Health History • Patient Demographics • Chief Complaint (CC) • History of Present Illness (HPI) • Symptoms Associated Review of Systems (ROS) • Past Medical History (PMH) • Family History • Social History • Patient’s Health Goals Medication History • Current Prescription Medications • Current Nonprescription Medications • Medication Adherence • Effectiveness • Allergies/Adverse Drug Reactions • Immunizations Health History • Demographics • Age • Gender • Chief Complaint/Reason for Visit • What is the patient’s problem? • Stated in their own words • “My nose is running and my throat is sore.” • “Dr. Brown told me to see you about diabetes.” History of Present Illness (HPI) • More detailed description of the CC • Subjective story given to you by the patient • Must be concise and in chronological order • Must include pertinent negatives as well as positives • PPQRSSTA Mnemonic HPI - PPQRSSTA • Precipitating (What caused the condition?) • Setting – what the patient was doing when the symptoms occurred • Palliative factors (What has provided relief?) • Things that make the symptoms better or worse • Quality (Describe the condition) • Specific descriptive terms of symptoms (sharp pain, black tarry stools) • Radiation (Is it localized? Where else does it occur?) • Usually used when assessing pain HPI - PPQRSSTA • Site/Severity (Where is the problem? How severe is it?) • Location – precise area of symptoms • Mild, moderate, severe • Temporal factors (When did the problem begin? How often does it occur?) • Timing - Onset, duration, frequency of symptoms • Associated symptoms/ROS (Are there any other symptoms?) • Ask ROS questions that relate to the organ system(s) and problem associated with the chief complaint • See decision trees and exclusions to self-care in the book for questions Review of Systems (ROS) Questions • Problem-specific close-ended questions related to the affected organ system(s) or problem determined by the patient’s CC and HPI • Asked to help confirm or rule out possible causes of the CC • Identify pertinent positives and negatives • Used in pharmacist assessments to narrow down and confirm the cause of the patient’s chief complaint and to determine the severity of the condition • Ex. Includes asking about exclusions to self-care, contraindication for therapies (medications, disease states), symptoms that indicate a more severe condition, etc. • Also used to assess for complications of disease states being managed Textbook ROS Resources: Allergy Exclusions for Self-Care Textbook ROS Resources: Allergy Symptoms ROS Questions: Allergy Examples • Respiratory • • • • • • • Do you have a history of asthma, COPD or other lung condition? Are you experiencing any wheezing? Are you experiencing any shortness of breath? Do you have a history of septal deviation? Do you have any sneezing? Do you have a runny nose? Are you experiencing any itching in your eyes, nose or throat? HPI in Practice • Not every component will always be used • Questions can be asked out of sequence • Let the story flow naturally • Never abandon a question with an incomplete answer • Listen to what the patient is saying Past Medical History (PMH) • What medical conditions does the patient have? • Includes • Previous illnesses • Previous injuries • Previous medical interventions • Considerations • Could any of the conditions be causing the patient’s CC? • Do any of the conditions exclude a patient from particular therapies? (ex. selfcare, contraindications, etc.) • How would suggested medications affect the patient’s current conditions? Family History • Includes medical history of immediate family members (kids/parents/siblings/etc.) • Age, disease status/progression, age of death, etc. • May predict risks for certain disease states • Consideration • May or may not impact the care plan • Ex. Does not usually impact self-care decisions, so not commonly assessed • May uncover need for preventative therapy • Ex. Tdap vaccine for patients around newborns • Ex. Risk of cardiovascular disease in patients with a family history of heart attack and stroke Social History (FEDTACOS) • Includes: Food (nutritional balance, restrictions) Exercise (obesity, musculoskeletal injury, health maintenance) Drugs (illicit drugs) Tobacco (smoking and smokeless) Alcohol (recreational vs. abuse) Caffeine (coffee, tea, soda, chocolate, energy drinks) Occupation/Living Arrangement (health related injuries, environmental exposures) • Sexual history (obstetric Hx, STDs, pregnancy prevention and planning) • • • • • • • • Considerations: • • • • Could items mentioned in the social history be contributing to the patient’s CC? Could a patient’s social history affect your recommendations? Are there any non-pharmacologic recommendations you could make for their CC? Think before you ask!!! Identify the Patient’s Health Goals • What are the patient’s health and functional goals? • Influenced by patient preferences and beliefs • What factors limit the patient’s options for treatment? • Socioeconomic factors • Lifestyle habits • Patient’s readiness to make changes Basic Medication History • Always ask about all current medications before recommending therapy • Remember to check for drug interactions • Always ask about the possibility of pregnancy in women of child bearing age • Use open-ended questioning • “What medications do you currently take?” • Remember to ask about OTCs, herbal medications and alternative therapies Comprehensive Medication History • Details of Current Therapies • Name, dose, route, frequency, indication, duration of therapy • Determine how the patient is actually taking the medication • Don’t just copy the bottle • Try to quantify PRN medications • Ask about barriers to adherence • • • • Perceived efficacy (How do you feel the medication is working?) Perceived side-effects (How are you tolerating the medication?) Difficulty with drug regimen (How of often do you miss taking the medication?) Affordability (Do you have any difficulty affording your medication?) • Details of Past Therapies • Reason for discontinuation, duration of therapy Allergies/Adverse Events • Always ask about allergies/adverse events before recommending a therapy • Double check the for risks of cross reactivity • Allergies (immune mediated) • Include drug, immunization, food, and environmental allergies • Describe the reaction • Rash, breathing problems, anaphylaxis, etc. • Ensure that it was an actual allergic reaction and not an adverse event • Ex. Rash cause by Bactrim • Adverse Events (intolerances/side effects) • Ex. stomach upset after taking ibuprofen Immunizations • Sometimes included in the medication history • Assess all patients for immunization needs • Opportunity to advocate for preventative health Objective Data • General Observations • Description of how the patient appears • Ex. distressed, comparison to stated age, hygiene, skin coloration • Vitals • Wt, Ht, BMI, BP, HR, RR, Temp, Pain level, etc. • Physical Examination • Ex. Description of skin lesions, heart and lung sounds • Additional Data • Pertinent labs • CBC, CMP, UA, micro, etc. • Rating scales / risk scores • ASCVD Risk, PHQ2, CHADS2 • Diagnostic tests/imaging • CT, MRI, ECG, EEG, X-ray, etc. Textbook Resource: Physical Assessment Collection Lab : History Taking for Pharmacists Collection Activity: Part 1 • Work in your assigned groups to complete the activity. • Using what you have learned about patient history taking, develop a structured and logical list of subjective and objective information you would want to collect from the patient and her/his medical record that is pertinent to the case. • For the subjective information, be sure to write out the exact questions you would ask the patient. You can use any resources available to you to develop your list. • Please write your list and questions in a Word Document and one submit the document to the assignment link in Moodle (one member from each group). • You will have 30 minutes to work on the case and submit your document in Moodle. Collection Activity: Part 2 • One group will be picked to interview the patient (Dr. Biddle) • All groups should document the information collected from the patient. • Time will be given for other groups to ask additional questions. • Keep the information collected on each patient for the next lab in 2 week. Collection Activity: Case #1 • Bob is a 20-year-old male student who presents to your pharmacy complaining of itchy, watery eyes and a runny nose. Collection Activity: Case #2 • Darlene is a 34-year-old female who comes in today complaining of a dry, hacking, non-productive cough. Collection Activity: Case #3 • Stuart is a 5-year-old patient who presents to the pharmacy with his mother who states he has a fever of 101℉. Collection Activity: Case #4 • Dave is an 18-year-old male who presents to the pharmacy complaining of difficulty falling asleep. Collection Activity: Case #5 • Amanda is a 16-year-old female who presents today complaining about an injury to her upper right arm. Patient Care Process Assignment (Rough Draft) • See instructions in Moodle • Upload to Moodle by 10:00am MST (8:00am AKT) on Tuesday, October 16th. • Bring a copy of your Patient Encounter Rough Draft to your lab session on October 16th or October 18th. • We will be using this during next week’s lab session. Patient Care Process Assignment(Final Draft) • See instructions in Moodle • Upload to Moodle by 5:00pm MST (3:00am AKT) on Monday, October 22nd.
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