Sunteți pe pagina 1din 30

Patient Assessment and Clinical

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:
1. Failure to greet patients, tell them who you are and
the purpose of your interaction with them.
2. Failure to find out what is bothering the patient
worries, concerns, issues how the patient feels
about their condition.
3. Accepting vague information too easily and not
probing to find out more specifics.
4. Failure to verify that what you thought you heard,
was what the patient really meant
5. Failure to encourage patient questions.
6. Failure to be responsive to patient questions.
Common Mistakes:
7. Not paying attention to the verbal and NON-verbal
communication messages sent by patients.
8. Avoiding information that is personal.
9. Using too many closed ended questions.
10. Allowing interruptions.
11. Drawing conclusions too soon.
12. Failure to provide appropriate information in the
form of counseling.
13. Not understanding the patients viewpoint.
14. 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
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
Develop a genuine acceptance, respect and
tolerance for your patients cultural values.
Recommendations to Enhance
Cultural Sensitivity
Acknowledge that you dont know everything and
ask your patients to explain the things you dont
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 patients world.
Meet and develop rapport with members of other

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
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
Questions asked in the
background of the pharmacists
mind while conducting patient
assessment activities:
Patient Assessment Questions:
Are any of the patients complaints or
abnormal objective/physical findings related
to drug therapy?
What are some other possible causes of the
patients complaints / symptoms?
Are each of this patients 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,
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
Does the patient know how to use this
medication correctly?
Is additional medication needed to resolve
the patients complaint / symptom?
Provides a permanent record of patient
Provides a record and evidence of pharmacy care
Communicates to other practitioners what you
have done.
Provides a legal record of what you have done.
Provides documentation for billing purposes.

Legally, if it isnt documented it wasnt
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.

Pharmacy Consultant Note
Athens Primary Care Pharmacy Clinic

Patient Name: Sample Patient
Consult Date: 10/03
Indication Medication
Nexium 40mg1 PO QD GERD Tramadol 50mg3 PO QAM Pain
Amaryl 2mg1 PO QD Type 2 diabetes Promethazine 25mgPRN Nausea
Diphenoxyalate/AtropinePRN Diarrhea Ketoprofen 20% in Lipoderm Geltopical Knee stiffness
Tricor 160mg1 PO QHS Cholesterol HCTZ 12.5mg1 PO QAM HTN
Altace 10mg1 PO BID HTN

Potential Problem Recommendation Recommendation For MD
Accepted Y/N (if no,
Blood pressure fluctuates greatly from day to day Add another BP med, possibly a CCB after complete evaluation

Y / N
Diabetes not well controlled Need to check A
s; pt. needs to check blood sugar, record it for
monitoring; add 2
drug if appropriate

Y / N
Amaryl has no refills Refill if appropriate

Y / N
Is cholesterol being controlled? Check lipids

Y / N
Pharmacy Student: J.C. Faculty Advisor: Dr. Matt Perri, Dr. Jennifer Phillips
The SOAP Note
Subjective complaints, symptoms, recent
history, past medical history, medication history,
allergies, social and family history, review of
Objective vital signs, physical findings from
examination, labs tests, blood levels of drugs,
medication profile.
Assessment critical thinking and analysis of the
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

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

Specific Data Needed:

Chief Complaint
A brief statement of why the patient is seeking
1-2 primary symptoms with their duration.
Recorded in the patients own words.
Remember, patients 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.
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

Specific Data Needed:
Review of Systems
Hepatic / Renal
Nervous system
Mental status
Endocrine system (diabetes and thyroid)
Male reproductive system
Female reproductive system