Pharmacists' Patient Care Process (PPCP) and Documentation PDF

Pharmacists’ Patient Care Process (PPCP ) and Documentation Sweta Andrews, Pharm.D. , MBA, BCACP, CPh Associate Professor of Pharmacy Practice LECOM School of Pharmacy  Objectives 1. Recognize the five steps in the Pharmacists’ Patient Ca...

Pharmacists’ Patient Care Process (PPCP ) and Documentation Sweta Andrews, Pharm.D. , MBA, BCACP, CPh Associate Professor of Pharmacy Practice LECOM School of Pharmacy  Objectives 1. Recognize the five steps in the Pharmacists’ Patient Care Process (PPCP) 2. State the purpose and types of documentation in health setting 3. Identify the key components of a SOAP note 4. Distinguish which type of information is placed under which section of the SOAP note 5. Explore the components of the SOAP note (Emphasis on S &O) 2  Pharmaceutical Care “The responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life.” (Hepler and Strand; 1989) Outcomes (What?) – Cure of a disease – Reduction or elimination of symptoms – Slowing the progression of a disease – Prophylaxis/prevention Process (Who?) – Team approach – Direct relationship with the patient – Occurs anytime anywhere 3  Elements of Pharmaceutical Care “The responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life.” (Hepler and Strand; 1989) Responsible provision of care Direct provision of care Caring Achieving positive outcomes Improving the patient’s quality of life (QOL) Resolution of medication-related problems 4 1. Pharmacists’ Patient Care Process 5  Pharmacists’ Patient Care process What are the 5 steps in the process? Joint Commission of Pharmacy Practitioners. Pharmacists’ Patient Care Process. Available at: https://jcpp.net/wp- content/uploads/2016/03/PatientCareProcess-with-supporting-organizations.pdf. May 29, 2014. 6  Pharmacists’ Patient Care process Most inner circle → Patient-Centered Care Next circle that connects all components of the process – Collaborate – Communicate – Document https://www.pharmacist.com/sites/default/files/files/PatientCareProcess.pdf 7  Standardization Reduce unnecessary variation Seek clarity between execution and terminology Consistent manner of delivery of service Adapt the process… – Setting – Diverse population – Acuity level 8  PPCP Step 1: Collect Collect information Data to collect – Subjective and objective – Current medication list To understand – Medication history – Medical history – Medication history – Relevant medical, health and wellness data, test results, – Clinical status physical assessment findings From sources – Lifestyle habits, preferences, – The patient goals, socioeconomic factors – Patient records – Other healthcare providers 9  PPCP Step 2: Assess Assess the information What to assess that was collected – For each medication Appropriate Analyze current status Effective compared to the patient’s Safe goals Patient adherence Identify problems Health status, risk factors, cultural factors, literacy, Prioritize problems access to care Immunization status and preventive care needs 10  PPCP Step 3: Plan Individualized Care plan – Address medication Patient-centered problems Care plan – Optimize medication therapy Collaborative with other – Set goals of therapy healthcare providers – Engage the patient Collaborative with the Education patient and caregivers Empowerment Self-management Evidence-based Continuity Cost-effective – Follow-up – Transitions 11 PPCP Step 4: Implement Follow the steps outlined in the plan Address problems and promote prevention Initiate, modify, discontinue, or administer medications as authorized Provide education Provide self-management training Participate in coordination of care Schedule follow-up care 12 PPCP Step 5: Follow-up Monitor and Evaluate – Medication appropriateness – Effectiveness – Safety – Patient adherence – Clinical measures of overall health – Outcomes of care and progress toward goals Use Data – Patient feedback – Health data – Biometric test results 13  Utilization of PPCP QuEST SCHOLAR-MAC – Over the Counter (OTC) medications and self-care Medication Therapy Management (MTM) – Community pharmacy and ambulatory care – OutcomesMTM website example of a CMR Comprehensive Medication Management – All settings – https://www.accp.com/docs/positions/misc/CMM_Care_Process.pdf SOAP Note Documentation – All settings 14  QuEST SCHOLAR-MAC Process for self-care recommendations given by pharmacists in the community pharmacy setting QuEST – Quickly and accurately access the patient (using SCHOLAR-MAC) – Establish if self-care is appropriate – Suggest appropriate self-care strategies – Talk with the patient 15  QuEST SCHOLAR-MAC Symptoms: What are the main and associated symptoms? Medications: prescription, non- Characteristics: What is the situation prescription, alternative, like? Is it changing? recreational History: What has been done so far? Allergies: to medications and Has this ever happened before? If so, other substances was treatment successful? What was Conditions: coexisting health not successful? conditions Onset: When did it start? Location: Where is the problem? Aggravating factors: What makes it worse? Remitting factors: What makes it better? 16 Subjective, Objective, Assessment, Plan (SOAP) Standard system of documentation used by many different healthcare providers Subjective and Objective = Collect – Subjective = open to interpretation – Objective = directly measured and reproducible Assessment Plan – Includes plan for monitoring and follow-up 17 2. Documentation (Purpose and Types) 18  Why is documentation in healthcare important? It is a part of standardized healthcare practice Provides a clear & concise idea of what is going on with the patient It ensures that workflow in practice is appropriate Required for timely payments from insurance companies Ensures continuity of care 19  Poor Documentation: Consequences? Medication and/or medical errors Difficulty understanding what is going on with patient Other physicians may provide inaccurate information to patient Other physicians may have trouble with identifying proper treatment for condition You (yourself) may have trouble recalling what you talked about with the patient If health records are available to patients – they may disagree with note documentation 20  What should be included in note documentation? Date and time Title for the note Printed name and contact information Signature and credentials If note documentation is done on paper: Write legibly Use blue/black ink Cross out mistakes with a single strike and initialed (legal document) Use appropriate grammar and spelling 21  Other Important Factors in Documentation Avoid error-prone abbreviations – May lead to mistakes – The Joint Commission has a list of unapproved abbreviations that should not be used Avoid long and wordy statements – Should be clear, succinct, and straight-forward Avoid commanding language – The physician should stop lisinopril vs. recommend discontinuation of lisinopril Avoid accusatory language – The patient is non-adherent because he does not care about his health vs. the patient displays signs of non- adherence 22  Types of Documentation Care Plan SOAP Notes (Subjective, Objective, Assessment, Plan) SBAR (Situation, Background, Assessment, Recommendation) 23  Why do we write Care Plans & SOAP Notes? To identify, resolve, and prevent drug-related problems To document any recommendations, suggestions, or interventions made To present collected data, prioritized problems, and assessments in an organized fashion to other healthcare professionals To document safety and appropriateness of medications Documenting when to monitor and what the outcomes are Document and assess one’s medication adherence 24  Pharmacists’ Patient Care Process Review health records and conduct patient Drug therapy interviews assessment and development of problem list Write SOAP note or care plan Establish goals and develop therapeutic recommendations Joint Commission of Pharmacy Practitioners. Pharmacists’ Patient Care Process. Available at: https://jcpp.net/wp- content/uploads/2016/03/PatientCareProcess-with-supporting-organizations.pdf. May 29, 2014. 25  Care Plans & SOAP Notes Benefits Challenges Identify important information to Time consuming collect, consider, and document Knowing what to include and exclude when providing care Effectively communicating Standardize documentation information to others component of patient care Improve documentation abilities of new pharmacists entering the workforce when included in pharmacy school curricula 26  Care Plan Components Prioritized problem list SMART goals of therapy – Each problem should have at least 3 SMART goals Therapeutic recommendations – Treatment and/or prevention – Non-pharmacological – Pharmacological Monitoring – Safety – Efficacy Follow-up 27  Care Plan Format Priority (1, 2, or Problem Pharmacotherapeutic SMART Goals Specific Monitoring 3) Recommendations & Parameters for Safety Counseling & Efficacy, Follow-Up  Sample Case: Mr. Lee Kalm HPI: Mr. Kalm comes to your pharmacy today for an OTC medication for a cough. He also decides to check his BP on the machine CC: I keep coughing up mucus! It’s been bothering me every night, and I have been sleeping poorly these past few nights! PMH: Hyperlipidemia, hypertension diabetes, cough Allergies: NKDA Vitals: – 150/92 mmHg (goal is < 130/80); HR 78 bpm; Ht: 62 in; Wt: 220 lbs Current Medications (from pharmacy profile): – Metformin 1000 mg PO BID – Januvia 100 mg PO daily – Amlodipine 10 mg PO daily – Atorvastatin 20 mg PO daily – Aspirin 81 mg PO daily  Care Plan Components Prioritized problem list SMART goals of therapy Therapeutic recommendations – Treatment and/or prevention – Non-pharmacological – Pharmacological Monitoring – Safety – Efficacy Follow-up  Prioritizing the Problem List 1. Priority 1 (Primary) Inpatient – what will cause the most harm or kill the patient first? Outpatient – what is the patient’s chief complaint? Exception: life-threatening situation 2. Priority 2 (Secondary) All other problems that should be addressed now or in a few days 3. Priority 3 (Tertiary) Problems that can be addressed on follow-up There will only be one primary problem; however, there may be multiple secondary and/or tertiary problems.  Medical & Drug-Related Problems Indication Indication – Unnecessary drug therapy (appropriateness) – Needs additional drug therapy Safety Safety – Adverse drug reaction – Dosage too high Effectiveness Effectiveness – More effective drug available – Dosage too low Adherence & Adherence/Convenience/Monitoring Monitoring – Nonadherence – Needs monitoring 32  Care Plan Components Prioritized problem list SMART goals of therapy Therapeutic recommendations – Treatment and/or prevention – Non-pharmacological – Pharmacological Monitoring – Safety – Efficacy Follow-up  Types of Therapy Goals Cure a condition Slow or halt disease progression Reduce or eliminate signs and/or symptoms Prevent disease Normalize lab values Each problem should have at least 3 SMART goals  Care Plan Components Prioritized problem list SMART goals of therapy Therapeutic recommendations – Treatment and/or prevention – Non-pharmacological – Pharmacological Monitoring – Safety – Efficacy Follow-up  Therapeutic Recommendations Initiate new Initiate new non- Substitute with pharmacologic pharmacologic Therapeutic therapy therapy Alternative Encourage Continue Drug Discontinue Drug Medication with Monitoring Adherence Refer to Physician Modify Medication (exclusion to self- Dose care)  Therapeutic Recommendations Be complete and specific – Any healthcare provider should be able to use your note to assume care Medication therapy should include: – Drug – dose – route – frequency – (duration) – Special instructions or counseling points Anticipate alternative recommendations  Care Plan Components Prioritized problem list SMART goals of therapy Therapeutic recommendations – Treatment and/or prevention – Non-pharmacological – Pharmacological Monitoring – Safety – Efficacy Follow-up  Monitoring & Follow-Up Assess achievement of therapeutic Indication goals (appropriateness) Assess patient for new problems Patient/practitioner agreement Safety Who will the patient follow- up with? Effectiveness When will the follow-up occur? What if: the patient need an Adherence & earlier follow-up? Monitoring Priority Problem SMART Goal Therapeutic Recommendations Monitoring for Effectiveness, (1,2,3) (Pharm & Non-Pharm) Safety, & Follow-Up Eliminate cough Pharm: Efficacy: 1 Cough within 1 week Recommend guaifenesin ER 600 mg Patient to assess for resolution of tablet PO BID x 7 days cough in 1 week Reduce chest congestion Non-pharm: Safety: within 1 week Gargle with warm saltwater each Patient to monitor for side effects of day and night. guaifenesin such as nausea, Increase vomiting, or abdominal pain daily sleeping time by Utilize humidifier throughout the during treatment at least 1 hour day and night to improve within 1 week congestion. Follow-Up: Patient to follow up with PCP for a sick visit within 1 week Priority Problem SMART Goal Therapeutic Recommendations Monitoring for Effectiveness, (1,2,3) (Pharm & Non-Pharm) Safety, & Follow-Up Reduce BP < Pharm: Efficacy: 2 HTN 130/80 mmHg Continue amlodipine 10 mg tablet Patient to monitor BP daily in the within 3 months PO daily morning during treatment Maintain BP < Recommend for PCP to initiate Safety: 130/80 mmHg lisinopril 5 mg tablet PO daily Patient to monitor for side effects within next 2 of lisinopril such as dry cough daily years Non-pharm: during treatment Recommend exercise for 30 mins 3-5 Prevent times a week to assist with losing Physician to obtain BMP to potential CV weight monitor for side effects of lisinopril events (MI, such as renal insufficiency or stroke) within Consume 5 cups of fruits/vegetables hyperkalemia in 1 month the next 5 years each day Follow-Up: Prevent target- Minimize sodium intake to 1.5 g/day Patient to follow-up with PCP in 1 organ damage month to reassess current BP such as kidney regimen failure & heart failure within the next 5 years.  Care Plan Summary Identify the drug & medical related problems Prioritize each problem Provide SMART goals (at least 3) Provide BOTH pharmacological & non- pharmacological treatment Include SMART monitoring parameters for efficacy & safety Follow-up  What is a SOAP Note? Subjective Objective Assessment Plan – Form of documentation – Based on patient encounter – History and Physical (H&P) – Communication tool (providers, billing for services, productivity, accountability, legal/liability issues) 43 What is SOAP? 44 3. Components of a SOAP Note 45  Key Components: SOAP Note Subjective: Include information from patient, such as CC, PMH, HPI, FH, SH, PSH, allergies Objective: Include pertinent labs, findings, vitals Remember: medication list may be subjective OR objective depending on the source of the information Assessment: Prioritize and characterize each problem and include statement of action Provide a brief rationale regarding selection or elimination of different therapeutic options Plan (for each problem): SMART goals (at least 3) Pharmacologic & non-pharmacologic treatment recommendations Counseling points if pertinent Monitoring parameters for BOTH efficacy & safety Follow-up Chief complaint (CC) Past medical history (PMH) History of present illness (HPI) Family history (FH) Social history (SH) Past surgical history (PSH) 46  Subjective vs. Objective Subjective Objective Any information collected directly from Information obtained through: or communicated by the patient (or ‐ Direct physical examination caregiver, family member) Head-to-toe order ‐ Demographics (age, gender, ‐ Laboratory analyses and other race/ethnicity etc.) tests or studies (vital signs, Chief Complaint: Abbreviated as “CC” diagnostic tests) ‐ Specific complaint for which ‐ Direct observation by provider patient is seeking care Any information that provider ‐ History of Present Illness (HPI) sees, smells, feels, and hears ‐ Details regarding patient’s primary ‐ Fact-based, quantifiable and reason for seeking care (7 reproducible attributes) Past Medical History: (PMH) Family History (FH) Social History (SH) Review of Systems (ROS) 47  Subjective vs. Objective Contd.. Subjective Objective Medication History (Allergies , Rx, Medication administration records OTC medications, Herbal products (MAR) documented by healthcare and supplements, personnel Vaccines/immunization status) Health and functional goals 48  Assessment vs. Plan Assessment Plan This is the synthesis section This is the final section Goals of therapy based on clinical It consists of proposed strategies to guidelines address the diagnosis/problem listed in the A section Clinician’s impression of which diagnostic label best describes the It includes monitoring, Follow-up and patient’s current problem Education (who will do what and when) Pertinent positive/negative information from the S component No new information should be along with pertinent positive/negative presented in this section information from the O section is used to identify/assess the problem(s) No new information should be presented in this section Ives TJ et al. Documentation of Pharmacist Interventions 49 Pearce PF et al. The essentials of SOAP note in an EHR age 4. Distinguish Sections SOAP note 50  SOAP Note Components Subjective: Include information from patient, such as CC, PMH, HPI, FH, SH, PSH, allergies Objective: Include pertinent labs, findings, vitals Remember: medication list may be subjective OR objective depending on the source of the information Assessment: Prioritize and characterize each problem and include statement of action Provide a brief rationale regarding selection or elimination of different therapeutic options Plan (for each problem): SMART goals (at least 3) Pharmacologic & non-pharmacologic treatment recommendations Counseling points if pertinent Monitoring parameters for BOTH efficacy & safety Follow-up  Subjective vs. Objective Subjective Information Objective Information Cannot measure Measurable Generally obtained through Generally obtained through patient interview observation and direct testing May be inaccurate or incomplete Reproducible Subjective + Objective = _______________  Subjective vs. Objective In a SOAP note, generally only data Subjective Data Objective Data pertinent to the problems should be Patient demographics Vital signs listed Chief complaint Calculations History of present illness Physical exam Past medical history Laboratory values Past surgical history Microbiology results Family history Diagnostic test results Social history Current medications Drug allergies Vaccination history Note: A patient’s current medication list may be either subjective OR Current medications objective, depending on the source of this information!  SOAP Note Components Subjective: Include information from patient, such as CC, PMH, HPI, FH, SH, PSH, allergies Objective: Include pertinent labs, findings, vitals Remember: medication list may be subjective OR objective depending on the source of the information Assessment: Prioritize and characterize each problem and include statement of action Provide a brief rationale regarding selection or elimination of different therapeutic options Plan (for each problem): SMART goals (at least 3) Pharmacologic & non-pharmacologic treatment recommendations Counseling points if pertinent Monitoring parameters for BOTH efficacy & safety Follow up  Assessment Evaluate subjective and objective information to develop the assessment Identify drug-related problems Prioritize each problem (#1-3) if there is more than 1 problem noted – Primary (#1): most important problem – Secondary (#2): problems to be addressed next – Tertiary (#3): problems that can be addressed later Each problem should be characterized and include a statement of the type of action that is needed to resolve the problem New onset diabetes requiring additional prescription therapy Characterization Action that is needed  Assessment After identifying, characterizing, and prioritizing the problems, each problem needs an evaluation and rationale – This is more of a discussion of why you are choosing one drug or therapy over another – Discuss why you eliminated certain choices as an option and why you chose other options instead New onset diabetes requiring additional prescription therapy Patient may benefit from initiation of first-line oral anti-diabetic medication, such as metformin. Insulin therapy is not warranted at this time due to A 1c