Patient Assessment and Clinical Interviewing

1
Patient Assessment and Clinical Interviewing
2
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.

3
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.

4
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.

5
Cultural Issues

• Home Remedies?

6
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?

7
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!

8
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 patients cultural values.

9
Recommendations to Enhance Cultural Sensitivity

• Acknowledge that you dont know everything and
  ask your patients to explain the things you dont
  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 patients world.
• Meet and develop rapport with members of other
  cultures.!

10
When will I need patient assessment or clinical
interviewing skills?
11
The Pharmacy Care Process
Collect and use patient information
Follow up to assess patient outcomes
Identify patients drug related problems
Select and recommend therapies
Develop solutions to these problems
12
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

13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
We want to differentiate assessment and
interviewing from counseling but the same
skills apply.

• One of the primary differences is documentation.

17
Questions asked in the background of the
pharmacists mind while conducting patient
assessment activities
18
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?

19
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?

20
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
  patients complaint / symptom?

21
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.

22
Documentation

• Legally, if it isnt documented it wasnt
  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.

23
(No Transcript)
24
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.

25
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.

26
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.

27
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.

28
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.

29
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 patients own words.
• Remember, patients may not always have a CC
  they may present with a problem they do not know
  is drug related.

30
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)

31
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.

32
Specific Data Needed

• Review of Systems
• General health
• Skin, hair and nails
• Eyes, ears, nose and throat
• Head and neck
• Respiratory system
• Cardiovascular
• Gastrointestinal

33
Specific Data Needed

• Review of Systems
• Hepatic / Renal
• Musculoskeletal
• Nervous system
• Mental status
• Endocrine system (diabetes and thyroid)
• Male reproductive system
• Female reproductive system