藥事執業技能：藥物相關問題之解決 Pharmacy Practice Skills: Drug-Related Problems Solving

1. 藥事執業技能：藥物相關問題之解決Pharmacy Practice Skills: Drug-Related Problems Solving

2. 課程目的 • 了解 systematic clinical drug monitoring 的重要性與目的 • 說明 SOAPing format 之組成及擷取藥事服務所需資訊 • 了解 patient case presentation 之結構及順序 • 學習以 SOAPing format 建立完整的合理用藥評估 • 藉案例學習，引導學生與指導老師充分互動 -重視討論的過程，而非結果

3. Systematic Clinical Drug Monitoring的重要性 • The responsibility of a pharmacist to provide services in a consistent and complete manner • The complexity of a patient’s health problems • The comprehensible communication among health care professionals

4. The Purposes of Systematic Clinical Drug Monitoring • Determine that all of a patient’s drug therapy is the most appropriate, most effective, safest, and most convenient available. • Identify any drug therapy problems (DTPs; DRPs) and the goal of therapy. • Identify any drug therapy problems (DTPs) the patient is at risk of developing in the future that is to say, any drug therapy problems the pharmacist must help the patient to prevent in the future

5. Pharmaceutical Care Process

6. Problem-Oriented Approach • In 1964, Lawrence E Weed published the problem-oriented approach to medical records, patient care, and medical education. • A systematic, disciplined approach to each patient is used • Noimportant therapeutic considerations are missed

7. Problem-Oriented Approach • Two main components • Complete problem list • Physical • Psychological • Social/financial • SOAP notes • Logical thinking process • 連結理論和臨床, 並應用在醫療照顧 • One visit one SOAP

8. POMRProblem Oriented Medical Record • Dr. Lawrence Weed 提出將病歷制式化的構想 POMR= Problem List (第 x 項) + 各個 SOAP • Problem 1+ SOAP 1 • Problem 2+ SOAP 2 • … … • Modified SOAP S O A (Problem 1, 2, …) P (Problem 1, 2, …)

9. 教學大綱 • 課程目標 • 病歷之基本組成 • Patient Case Presentation • From database to plan • 1. From data base to assessment (SOAP notes) • 2. Assessment • 3. From assessment to plan (Implentation) • SOAPing format • 案例說明 • Daily SOAP note • Oral case presentation

10. 教學內容重點

11. 實際指導學生實習-案例討論 • 課程準備 • 安排課程表-學習過程 • 準備內容教材(挑選主題, 範例, 實例, workbook, pharmacotherapy之參考依據) • Disease Management Case Demo (ASHP’s PharmPrep 2001) • Terry L. Schwinghammer pharmacotherapy Casebook 6th Ed. • 課程分配 • 需多堂課 (10幾個小時) • 漸進地介紹,才能完成 • 1. 上課解說 2小時 • 2. 範例說明 1小時 • 3. 學生實例演練 SOAPing format及討論 (2小時/次, 共 5-6次)

12. 病歷之基本組成

13. 病歷之基本組成 • 首頁 • 門診病歷 • 住院病歷 • 急診病歷

14. 住院病歷 • 病歷摘要 (Discharge summary) • 醫囑單 (一般 / 特殊 -TPN 及 C/T) • TPR sheet • Admission note (內科及外科 / 一般或各專科病歷用紙) • Progress note (SOAP format) • 會診記錄 • 治療申請單 (X-ray, Cath, RT) • 檢驗報告 (Lab data) • 監測觀察記錄單 (GCS, APACHE II scale) • 輸入輸出記錄表 / 膀胱訓練記錄表 • 手術記錄 • 給藥記錄 • 護理評估表/ 護理記錄 • 出院準備服務 個案篩選表 / 收案病患記錄表

15. Medication Administration Record(MAR) • Routine or maitenance • Antibiotics, anticonvulsants • P.R.N. • Usually are listed at the end of the MAR • Fever (if >38.5℃) • Pain medication • Antiemetics • Sedative-hypnotic agents • Stat(Statim, immediately) • Administeredonceand not repeated unless recorded • Given as soon as possible • Prescribed in life-threatening or emergency situations • One time order • Given as soon as convenient and sometimes can be scheduled ahead of time • C/T

16. 住院日誌 Progress Note • 目的 提醒每天病人發生了什麼事以及醫師目前的想法 • 精神-忠實記錄, 簡短(縮寫), 清晰易讀, 遵守常用習慣 • 重要性 • 對病患病程的演進，客觀的變化，醫師的判斷，臨床的因應做一個重要的記錄 • 對病患而言，這是他的”傳記”，是他一生最重要的記錄 • 對醫師而言，這是他訓練過程的”事證”，對自己的想法與做法留下記錄;也是醫師間溝通的工具 • 對醫療而言，是醫療的重點記錄，是疾病處理的基本依據，是繼續醫療的重要參考 • 對醫學而言，是人類醫學的重要資產，是醫學進步重要文獻 • 格式-SOAP format

17. 常用縮寫 • 一般身體評估(身體診察) • 疾病診斷 • 藥品及其用法 • 檢查名稱

18. 推薦讀物 (入門) • 醫護專用縮寫辭典 (杜武志 主編) • 取材範圍廣泛 • 醫, 牙, 藥, 護, 檢驗, 管理 • 疾病診斷, 理學檢查, 名稱, 病歷用語 • 台大內科住院醫師醫療手冊 (楊汾池 總編) • 一般內科訓練 (primary care training) • 綜論 (醫療實務要點, 各病房特殊檢查及術後照顧) • 各論 (CV, GI, Nephro, Chest, Endo, Neuro, Rheuma, ID, Hema, Oncology) • The Washington Manual of Medical Therapeutics 31ed. • Clinical skills for pharmacists, A patient-focused approach. 2nd Ed. Karen J. Tietze, Mosby

19. Patient Case Presentation The accepted tool for documenting and communicating patient information (suggested by Tietze, K.J.)

20. General information Chief complaint (CC) History of present illness (HPI) Past medical history (PMH) Medication history (MedHx) Family history (FH) Social history (SH) Review of systems (ROS) Physical examination (PE) Pertinent positive and negative laboratory and diagnostic test results (Labs) P’t problem list and initial plans P’t progress Discharge data Final diagnosis Discharge medications Plans for follow-up Componentsof the Patient Case Presentation

21. General information (Gen) ↓ Chief complaint (CC) ↓ History of present illness (HPI) ↓ Past medical history (PMH) ↓ Social history (SH) ↓ Family history (FH) ↓ Medication history (MedHx) ↓ ↓ Review of systems (ROS) ↓ Physical examination (PE) ↓ Laboratory and diagnostic test results (Lab) ↓ Problem list and initial plans (SOAP format) ↓ P’t progress to date (SOAP format) Suggested Sequence for Presentation of Information

22. From database to plan Steps of Systematic Clinical Drug Monitoring (suggested by Shao C, Chiang, Pharm.D., R.Ph.)

23. Problem Conversion Medical problems (Dx) Medication problems (Drug therapy problems)

24. From Database to Plan • 1.From data base to assessment • SOAP notes • 2.Assessment • 3.From assessment to plan (Implentation) • Therapeutics planning-pharmacist • Diagnostic • Therapeutic (Prescription) • Educational (p’t) • Monitoring

25. 1.From data base to assessment (SOAP notes) At admission (new p’t)

26. SOAPing

27. 2. Assessment At admission (new p’t)

28. Interpret the Findings in Terms of the Probable Process • Pathological process • Congenital / Inflammatory • Immunological / Neoplastic • Metabolic / Nutritional • Degenerative / Vascular • Traumatic / Toxic • Pathophysiological • Psychopathophysiological • Drug-related

29. Make One or More Hypotheses about the Nature of the Patient’s Problem • Select the most specific and central findings around which to construct your hypothesis. • Match your findings against all the conditions you know that can produce them. • Eliminate the diagnostic possibilities that fail to explain the findings. • Weigh the competing possibilities and select the most likely diagnosis from among the conditions that might be responsible for the patient’s findings • Give special attention to potentially life-threatening and treatable conditions

30. 3.From assessment to plan(Implentation) Therapeutics planning At admission (new p’t)

31. Components of Therapeutics Planning * Regimens- initial & alternative

32. The Planning Process • Problem identification • Identification of subjectiveandobjective parameters • Grouping of related parameters • Assessment of the parameters and determination of specific p’t problems • Problem prioritization: Identify active and acute problems • Selection of specific therapeutic regimens • Creation of a list of therapeutic options • Elimination of drugs from the list based on p’t-specific and external factors • Selection of dosage, route, and duration of therapy • Identification of alternative therapeutic regimens • Creation of a monitoringplan • Monitoring and modification of the regimens as necessary

33. Common Subjective Parameters

34. Common Objective Parameters

35. Factors to Consider when Selecting a Specific Therapeutic Regimen • Patient-specific factors • What regimens have effectivelymanaged the problem in the past？ • What regimens have not effectively managed the problem in the past？ • How might other patient problems influence the proposed regimen？ • How might the proposed regimen influence other patient problems？ • External factors • Current “state of the art” therapeutics • Cost of the proposed therapv • Formulary limitations

36. Guidelines for Altering Initial Drug Therapy • If the regimen is ineffective, change the drug if the following are true • The patient received an adequate trial of the drug • The patient received an adequate dosage of the drug • The patient is compliant • If the regimen is associated with life-threateningside effects, discontinue the drug • If the patient is not complying with regimen because of unacceptable side effects, discontinue the drug • If the patient has non-life-threatening side effects and is willing to continue the drug, • minimize the side effects by doing the following: • Adjust the dosage of the drug • Change the timing of the dose

37. 3.From assessment to plan (Implentation) Monitoring At admission (new p’t)

38. Data acquisition and assessment Patient monitoring Problem identification and prioritization Therapeutic planning Patient-Focused Care CycleA Never-Ending Cycle

39. The Process of Monitoring Therapeutic Regimens • Set therapeutic goals • Determine patient- and drug-specific monitoring parameters • Integratethe monitoring plan • Obtain data • Assess the response to therapy • Alter the therapeutic regimen if necessary • Repeat Step 1-6

40. Organization of Monitoring Parameters (The Four-Square Method)

41. Steps of systematic clinical drug monitoring at inpatient setting Hospital stay (old p’t)

42. Hospital Stay • Daily SOAP note • Each problem has its own SOAP note. • The subjective and objective data should include the values of drug monitoring parameters. • All problems should be assessed and planed, unless the problem has been resolved • Daily drug monitoring

43. Real Practice Setting • With time and practice, the process of assessing patient therapy and prioritizing the need to make an intervention becomes second nature and does not require a concerted effort to mentally check off each step after it has been performed. • Setting priority about which patients require more in-depth intervention.

44. SOAPing format

45. SOAPing Format • SOAPing The processof identifying the subjective and objective data, assessing the problem, and developing a specific therapeutic and monitoring plan • A formal organizationl structure • Steps • Creation of a list of related subjective parameters • Creation of a list of related objective parameters • Assessment and documentation of the problem • Documentation of the therapeutic plan for addressing the problem

46. Thinking Process Tips • Problem identification • Desired outcome • Therapeutic alternatives • Optimal plan • Outcome evaluation • Patient education

47. Problem List

48. SOAPing FormatUSC School of Pharmacy Kathleen Besinque Pharm D, MS Ed.)

49. Current Drug-Therapy Problems

50. Current Drug-Therapy Problems