Clinical Communications: Patient Interview & History

• These notes pertain to clinical communications, focusing on patient interviews, medication history, identifying drug therapy problems, motivational interviewing, adherence, interprofessional communication, telehealth, documentation, patient counseling, and communication with children and older adults.

The Patient Interview/Medication History

• Ensures an accurate and up-to-date medication list for all patients.
• Assesses drug-related needs and identifies potential drug therapy problems.
• Aims to develop a therapeutic relationship between the pharmacist and the patient.

Important Questions During a Patient Interview

• Chief Complaint: "What brings you to the clinic today?" and "What would you like me to help you with regarding your medications?"
• History of Present Illness: "How long has this been happening?" and "Has anything made it better/worse?"
• Past Medical History: "Tell me about any serious illnesses or medical problems you have had."
• Medication History: "What other medications have you taken in the past for these same symptoms/problems?"
• Medication Experience and Personal Goals: "What concerns do you have about taking medications?" and "How do you remember to take your medication?"
• Vital Signs/Laboratory Test Results: "If your doctor orders blood tests, where do you have those done?" and "What lab work have you had done recently?"
• Allergic Reactions and Drug Intolerances: "Tell me about your medication allergies."
• Social History: "How often do you have alcohol?" and "Are you now, or have you ever been, a smoker?"
• Lifestyle: "Tell me about what you typically eat." and "What did you have for breakfast today?"
• Vitamin/Herbals: "Do you use any over-the-counter or herbal medications or vitamins?"
• Frequency of Missed Doses: "How often would you say you miss a dose of this medication?"
• Adverse Effects: "Sometimes people experience _____ when they take this medication."
• Surrogate Outcome or Disease-Oriented Outcome: "When was the last time you checked your BP at home?"
• Patient Goals: "Have you noticed any difference in how frequently you _____?"

Assessing/Identifying Drug Therapy Problems

• A Drug Therapy Problem (DTP) is any undesirable event involving drug therapy.
• DTPs interfere with achieving desired therapy goals and require professional judgment to resolve.
• Types of DTPs: Indication, effectiveness, safety, and adherence.

Categorizing Drug Therapy Problems

• Indication: Includes unnecessary drug therapy and needs additional drug therapy.
• Effectiveness: Includes ineffective drug and dosage too low.
• Safety: Includes adverse drug reaction and dosage too high.
• Adherence/Compliance: The patient either does not understand the instructions or prefers not to take the medication.

Questions to Elicit Drug Therapy Problems

• Indication: "What medications are you taking for (condition)?"
• Effectiveness: "Did the symptoms improve after starting this medication?"
• Safety: "What side effects have you noticed?"
• Adherence: "How often do you forget to take your medications?"

Statements Describing a Drug Therapy Problem

• A good DTP statement includes both the condition and the medication.
• Example for effectiveness: "This 29-year-old is having continued breakthrough seizures due to subtherapeutic phenytoin concentrations."
• Example for safety: "This 61-year-old male is experiencing gastrointestinal bleeding secondary to aspirin therapy."

Prioritizing Drug Therapy Problems

• Depends on the severity of potential harm, the patient's perception of risk or urgency, and the rate at which the harm might occur.

Motivational Interviewing (MI)

• Acknowledges change as an option.
• Develops discrepancies between patients' thoughts and goals.
• Understands patients' reasoning with an open mind.
• Reinforces that there is no single right way to change.

Three Key Elements of Motivational Interviewing

• Collaboration is favored over confrontation
• Evocation is favored over imposing
• Autonomy is favored over authority

Examples of When to Use Motivational Interviewing

• Obesity, diabetes, hypertension, medication adherence, psychiatric illness, behavior disorders, substance abuse, nicotine dependence.

Communication Strategies for Motivational Interviewing

• Open-ended questions: Invite patients to tell their story.
• Reflections: Repeat or rephrase what the patient says.
• Express empathy: Acknowledge challenges in decision-making.
• Develop discrepancy: Recognize ambivalence.
• Summarize: Use at transition points.
• Affirmations: Recognize patient strengths.
• Roll with resistance: Avoid direct confrontation.
• Support self-efficacy: Focus on previous successes.
• Elicit and reinforce change talk: Listen for desire, ability, reasons, and need (DARN).
• Set SMART goals: Specific, Measurable, Attainable, Relevant, Time-based.

Examples of SMART goals

• Specific: I will eat at least two servings of vegetables with each meal.
• Measurable: I will log my meals in a food tracking app.
• Attainable: Add one serving of vegetables to lunch each day for the first week.
• Relevant: Improve my nutrition and support weight loss.
• Time-based: Achieve the goal within the next 3 weeks.

Adherence

• Compliance: The extent to which a patient's behavior matches the prescriber's recommendations.
• Adherence: Patient's ability and willingness to take a therapeutic regimen.
• Concordance: An agreement reached after negotiation between a patient and a health care professional.

Reasons for Less-Than-Optimal Adherence

• Patient-related: Perception of the medication, perception of the severity of the illness.
• Provider-related: Pill burden and a negative patient-provider relationship.
• Health system-related: Lack of access to medication.

Techniques to Improve Patient Understanding

• Emphasize key points and give reasons for key advice.
• Supplement counseling with written information.

Types of Nonadherence

• Intentional and unintentional.
• Patient-related, Provider-Related, and Health System-Related.

Interprofessional Communication

• Reduced medication errors and overall costs.
• Improved adherence.
• Better BP and A1C control.

Behaviors of Collaborative Partnerships

• Similar agendas.
• Trust and shared vision
• Demonstration of respect

Collaborative Practice Agreement (CPA)

• Formal relationship between the provider and the pharmacist.
• Defined activities delegated.
• Chronic illnesses such as hypertension and diabetes are appropriate for CPAs.

ISBAR Steps For Communicating with a Provider

• Introduce, Situation, Background, Assessment, Recommendation

Telehealth Services

• Synchronous: Real-time communication like phone calls and video visits.
• Asynchronous: Communication not in real-time like secure messaging

Benefits of Telehealth

• Improved patient access and provider efficiency.
• Ability to avoid germs and overall expansion of care.

Challenges of Telehealth

• Technology access and literacy along with the need for private and secure areas.
• Security concerns and reimbursement.

Documenting Pharmacists' Interventions

• Provides a record of what happened and why
• Facilitates workload analysis and accreditation reporting

Components of a SOAP Note

• Subjective: Chief complaint, History of present illness, allergies
• Objective: Vital signs, Physical exam, Lab results
• Assessment: Current status of condition(s), goals of therapy, identified drug therapy problems
• Plan: Medication adjustments, therapeutic alternatives and rationale

Patient Counseling

• Educates and prepares patients and builds relationships
• Avoids drug therapy problems

Required Content in Patient Counseling

• Medication name and description.
• Dosage form and route.
• Intended use and expected action.
• Special directions and precautions.
• Common severe side/adverse effects, and interactions

Prime Counseling Questions

• Purpose: "What did your doctor tell you the medication is for?"
• Use: "How did your doctor tell you to take it?"
• Expectations: "What did your doctor tell you to expect?"

Counseling Children

• Address common medication errors at home by including children in counseling sessions.
• Dosage form and treatement duration are recommended info components
• Adapt education to cognitive development: sensorimotor (0-2 yrs), pre-operational (2-7 yrs), concrete operations (7-12 yrs), formal operations (13+ yrs).

Strategies for Rapport With Children/Adolescents

• Sit at their level and keep eye contact.
• Involve the child in the interaction.

Communicating With Older Adults

• Consider internal factors (pharmacist and patient), communication styles, and sensory/emotional factors.
• Overcome barriers like attitudes, interfering behaviors, depersonalizing actions, and environmental issues.
• Be aware of hearing, vision, and cognitive impairments.