The purpose of the assessment is to determine if the patient's drug-related needs are being met and if any drug therapy problems are present.
Know your patient by understanding his or her medication experience before making any decisions about his or her drug therapy.
Elicit only relevant information necessary to make drug therapy decisions.
Always assess the patient's drug-related needs in the same systematic order. First determine if the indication is appropriate for the drug therapy. Second, evaluate the effectiveness of the drug regimen for the indication. Third, determine the level of safety of the drug regimen. Only after determining that the drug therapy selected or being used by the patient is appropriately indicated, effective, and safe do you logically evaluate the patient's adherence to the medication regimen.
Documentation includes the practitioner's assessment of how well the patient's drug-related needs are being met and a description of the drug therapy problems present.
The primary purpose of the assessment is to determine to what extent the patient's drug-related needs are being met. In order to accomplish this, the practitioner gathers, analyzes, researches, and interprets information about the patient, the patient's medical conditions, and the patient's drug therapies. Individuals can have drug-related needs whether they are taking medications or not.
This chapter describes how all of these activities combine to create an assessment of the patient's drug-related needs. A consistent format will be used to describe the standards of care and the corresponding measurement criteria that apply to the assessment step of the patient care process.
The assessment step in the patient care process is the most important of the three: (1) the assessment, (2) the care plan, and (3) the follow-up evaluation. It requires work on the part of the clinician and cooperation on the part of the patient. There are standard sets of issues and questions the practitioner must constantly think about and analyze throughout the assessment. The assessment interview is the means through which the practitioner encourages the patient's participation in the patient care process. The assessment interview influences all other components of the patient care process. It influences communication, data accuracy, clinical decision making, ethical judgments, patient adherence, patient satisfaction, practitioner satisfaction, and clinical outcomes.
Key Clinical Concepts
The personal, one-to-one nature of the assessment process creates the context to demonstrate caring and patient-centeredness.
There are essential clinical skills that each practitioner must develop in order to conduct a productive assessment. These include inquiry, listening, and observational skills. You must be committed to learning and teaching yourself the skills needed to assess the drug-related needs of your patients.
To be successful, you must understand and master the basic skills as well as the pharmacotherapy knowledge required to conduct a comprehensive assessment of your patient's drug-related needs because over a 40-year career, a clinician will conduct over 160,000 patient assessments.1