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THE PATIENT CARE PROCESS

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The patient care process is a systematic and comprehensive method for interacting with patients that is applied consistently to every patient seen by the healthcare provider. The process may vary among healthcare practitioners who have different purposes and goals. For pharmacists, the primary purpose of the patient care process is to identify, solve, and prevent drug therapy problems.1 A drug therapy problem is “any undesirable event experienced by a patient which involves, or is suspected to involve, drug therapy and that interferes with achieving the desired goals of therapy and requires professional judgment to resolve.”1 The pharmacist’s patient care process includes three essential elements: (1) assessment of the patient’s drug-related needs; (2) creation of a care plan to meet those needs; and (3) follow-up evaluation to determine whether positive outcomes were achieved. Consequently, development of a care plan is only one component of the overall patient care process. Before developing a patient-specific care plan, it is important for the clinician to understand the comprehensive nature of the patient care process. This process offers a logical and consistent framework that can be most useful in care planning and serves as the framework for this chapter.

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ASSESSMENT OF DRUG-RELATED NEEDS

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The first step in assessment is to identify the patient’s drug-related needs by collecting, organizing, and integrating pertinent patient, drug, and disease information. In the patient care process, as with all direct patient care services, the patient is the primary source of information. This involves asking patients what they want (expectations) and what they do not want (concerns) and determining how well they understand their drug therapies. For example, the clinician may ask, “How may I help you today?” or “What concerns do you have that I may address for you today?” In addition to speaking with the patient, data can also be obtained from: (1) family members or caretakers when appropriate; (2) the patient’s current and past medical records; and (3) discussions with other healthcare providers. The types of information that may be relevant are described below.1,2

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Patient Information
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  • Demographics and background information: age, gender, race, height, and weight.

  • Social history: living arrangements, occupation, and special needs (eg, physical abilities, cultural traits, drug administration devices).

  • Family history: relevant health histories of parents and siblings.

  • Insurance/administrative information: name of health plan and primary care physician.

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Disease Information
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  • Past medical history.

  • Current medical problems.

  • History of present illness.

  • Pertinent information from the review of systems, physical examination, laboratory results, and x-ray/imaging results.

  • Medical diagnoses.

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Drug Information
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  • Allergies and side effects (include the name of the medication and the reaction that occurred).

  • Current prescription medications:

    • ✓ How the medication was prescribed.

    • ✓ How the patient is actually taking the medication.

    • ✓ Effectiveness and side effects of current medications.

    • ✓ Questions ...

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