The Medical Record - Jones & Bartlett Learningsamples.jbpub.com/9781449652722/9781449645106_ch02_037_064.pdf · The medical record can be dissected into five primary components, including

Chapter 2

Learning Objectives

• Explaintheimportanceofbeingproficientinnavigatingapatient’smedicalrecord.• Outlinethegeneralcomponentsofapatientmedicalrecord.• Describepaper-basedandelectronicmedicalrecords.• Describeasystematicmethodforcollectinginformationfromapatient’smedicalrecordforthepurposeofdevelopinganassessmentandplan.

• Identifyanddefinekeypharmacy-relatedcomponentswithinapatient’smedicalhistoryandphysicalexamination.

• Synthesizepatientinformationtodevelopacomprehensiveproblemlist,includingdrug-relatedproblems.

TheMedicalRecord

Linda M. Spooner, PharmD, BCPS

Kimberly A. Pesaturo, PharmD, BCPS

• Drug-relatedproblems• Historyandphysical(H&P)• Problemlist

Key terms

intrOductiOn

As pharmacists continue to increase their involvement in patient care activities,their ability to navigate the often murky waters of the medical record becomesevenmore crucial.Locating vital piecesof information is critical todeveloping anappropriate assessment and plan for the individual patient. Additionally, collecting

thisdatainasystematicwaywillpermitthepharmacisttothensynthesizeitandcreateacomprehensivelistofhealthcareneedsandconsiderationsforthepatient,regardlessofthepracticesetting.

impOrtance Of prOficiency in navigating the patient’s medicaL recOrd

Itcanbeextremelyoverwhelmingtothinkaboutthevastquantitiesofmedicalinfor-mationeverypersonhasaccumulatedoveralifetime.Eventheamountofdocumenta-tionrequiredduringahospitalstaycanbequitelengthy,whichcanmakeitdifficultto locate specific data critical to drug therapy selection and assessment of patientresponse.Compoundingtheseissuesisthefactthateveryinstitutionandclinichasadifferentmethodfororganizingpatients’medicalinformation.Becausemostencounterswithpatientsoccurovermorethanonepointintime,

theuseofamedicalrecordfacilitatesthedocumentationofalldatacollectedovertime.Inboththehospitalandclinicsettings,themedicalrecordtakestheformofa patient chart composed of printedmaterials in a folder or binder (paper-basedchart)orwithinacomputersystem(electronicmedicalrecord),oracombinationofthetwo.Regardlessofthesystemusedbyaninstitutionorclinic,thegeneralorderofthemedicalrecordissimilar,asshownintable 2.1.Dependingupontheindi-vidual patient’s characteristics, the inpatientmedical record canbequite lengthy,especiallywhentherearenumerouscomorbiditiesorcomplicationsthatrequirealong hospitalization. Similarly, the outpatientmedical record can become exten-sivewhenapatienthashadnumerousencounterswiththepractitionerovermanyyears’ time.Developing familiaritywithwhere to findvitalpiecesof informationmakesthedevelopmentofanassessmentandplanmoreefficientandeffective.Thefirst step is understanding the contents containedwithin each component of themedicalrecord.

cOmpOnents Of a patient’s medicaL recOrd

Themedicalrecordcanbedissectedintofiveprimarycomponents,includingthemedicalhistory(oftenknownasthehistory and physical,orh&p), laboratoryanddiagnostictestresults,theproblemlist,clinicalnotes,andtreatmentnotes.1,2 SubheadingsforeachcomponentarelocatedinTable2.1.Itisimportanttonotethatalthoughphysiciansandotherprescribersmayusethisformatasamethodfortheirdocumentationpharmacistsmayusedifferentformatsfortheirownrecords.

38 chapter 2 / the medical record

tabLe 2.1 components of a patient’s medical record

Medical history (also known as history and physical, or H&P)

• Patientdemographics

• Chiefcomplaint(CC)

• Historyofpresentillness(HPI)

• Pastmedicalhistory(PMH)

• Familyhistory(FH)

• Socialhistory(SH)

• Allergies

• Medicationhistory

• Reviewofsystems(ROS)

• Physicalexamination(PE)

Laboratory test results

Diagnostictestresults

Problemlist

Clinicalnotes

• Progressnotes

• Consultationnotes

• Off-servicenotes/transfernotes

• Dischargesummary

Treatmentnotes

• Medicationorders

• Surgicalproceduredocumentation

• Radiationtreatments

• Notesfromancillarypractitioners

components of a patient’s medical record 39

medical history

Themedicalhistory,orH&P,includesthefollowingcomponents:

• patient demographics. Thissectionincludesthepatient’sname,birthdate,address,phonenumber,gender,race,andmaritalstatusandthenameoftheattendingphysician.Thissectionmayalsoincludethepatient’sinsuranceinfor-mation,pharmacynameandphonenumber,andreligiouspreference.

• Chief complaint (CC).Thechiefcomplaintistheprimaryreasonthepatientispresentingforcare.Oftenexpressedusingthepatient’sownwords,itincludesthesymptomsthepatientiscurrentlyexperiencing.AttimestheCCisnotreally a “complaint” at all; the patientmaybe presenting to the pharmacyto have a prescription filled ormay be coming to the clinic for an annualphysicalexam.

• history of present illness (hpI).ThehistoryofpresentillnessexpandsupontheCC,fillinginthedetailsregardingtheissueathand.TheHPIistypicallydocumentedinchronologicalorder,describingthepatient’ssymptomsindetailaswellasdocumentingrelatedinformationregardingprevioustreatmentfortheCC,previousdiagnostictestresults,andpertinentfamilyandsocialhistory.Additionally,pertinentnegativefindingsarelocatedintheHPI;theseincludesymptomsthepatientisnotcurrentlyexperiencingthatprovidemoreinforma-tiononthecase(e.g.,apatientpresentingwithvomitingwhonotesthathedoesnothaveabdominaldiscomfort).

• past medical history (pMh).Thepastmedicalhistoryincludesalistofpastandcurrentmedicalconditions.Pastsurgicalhistory(PSH)isoftenincludedwithin the PMH, as are previous hospitalizations, trauma, and obstetricalhistory(forfemalepatients).

• Family history (Fh).Thefamilyhistoryincludesdescriptionsoftheage,sta-tus(deadoralive),andpresenceorabsenceofchronicmedicalconditionsinthepatient’sparents,siblings,andchildren.

• Social history (Sh).This section includes a large amount of informationregarding the patient’s lifestyle and personal characteristics, including thepatient’s use of alcohol, tobacco, and illicit drug use, each documented astype,amount,frequency,anddurationofuse.Thesocialhistoryalsoincludesdescriptionsof thepatient’sdietaryhabits,exerciseroutine,anduseofcaf-feine as well as years of education, occupation, marital status, number ofchildren, sexual practices and preferences, military history, and currentlivingconditions.


• allergies. Although some H&Ps include allergy information in a general“medicationhistory”section,manymedicalrecordsprovideaseparatehead-ingtodenoteanyhistoryofallergicreactionsapatienthashadtomedications,foods,vaccines,stings,andcontrastmedia,aswellaswhattypeofhypersen-sitivityreactionoccurswhenapatientisexposedtotheagent,includingrash,hives,oranaphylaxis.

• Medication history. Information regarding thepatient’s currentmedicationlistmaybefoundinseveralareasoftheinpatientchart,includingaresident’sinitial H&P, the medication reconciliation form, and nursing intake notes.Reviewingeachof theseareasmaybenecessary togathera complete listofcurrentmedications (prescription, nonprescription, and complementary andalternative medicines), dosages, frequency of administration, duration oftherapy,reasonfortaking,andadherence.

• review of systems (rOS).ThereviewofsystemsportionoftheH&Ppro-videsinformationregardingthesubjectivefeelings,orsymptoms,thepatientisexperiencing.Conductedinhead-to-toeorder,positivefindingsandpertinentnegative responses are documentedoverall and for eachorgan system.ThisinformationisinadditiontothoseROSlocatedwithintheCCandtheHPI.TheusualorderofROSisprovidedintable 2.2.

• physical examination (pe). The physical examination contains objectiveinformation obtained from the practitioner’s examination of the patient. Asmentionedpreviously,subjectiveinformationistypicallyexcludedfromthePE,allowingforinclusionofinformationgatheredbythepractitioneruponobserv-ingandtouchingthepatient.LiketheROS,thePEisdocumentedinahead-to-toeformat,permittingstraightforwardreviewofallorgansystems.Oneofthemostcommonsequencesislistedintable 2.3.

Laboratory test results

Initial laboratory results are documented following the initialH&P.Most patientswill have a basicmetabolic panel and complete blood count (CBC) in addition toother parameters specific to their diagnosis andmedical conditions, including, butnotlimitedto,cardiacenzymes,serumdrugconcentrations,internationalnormalizedratio(INR),liverfunctiontests,andculturesofbloodorotherbodyfluids.Calculatedvalues,suchasaniongapandcreatinineclearance,arealsodocumentedinthissection.Computer systems are commonly used to collect and manage laboratory test

results.Occasionally, resultsmaybeprintedandplaced in thepapermedicalchart;


tabLe 2.2 Order and contents of review of systems

body system examples of contents

General Overallfeelingsofwellness,weightgainorloss,fever,chills,nightsweats,fatigue,weakness

Skin Changesincolor,dryness,hairloss,rashes,pruritis,bruising,bleeding

Head Headaches,trauma,syncope

Eyes Changeinvision(blurryvision,doublevision,floaters),trauma,useofcorrectivelenses

Ears Changeinhearing,tinnitus,vertigo,pain

Nose Discharge,stuffiness,epistaxis

Mouth Soreness,gumbleeding,issueswithteeth

Throat Difficultyswallowing,painfulswallowing,changeinvoice

Neck Pain,stiffness,swelling,lumps

Respiratorysystem Shortnessofbreath,dyspnea,wheezing,cough(dryvs.produc-tive),orthopnea,hemoptysis

Cardiovascularsystem Chestpain,palpitations

Gastrointestinalsystem Nausea,vomiting,constipation,diarrhea,abdominalpain,hematemesis,melena,hematochezia,jaundice

Genitourinarysystem Urinaryfrequency,urgency,hesitancy,dysuria,hematuria, incontinence, pain

Females:Vaginaldischarge,discomfort,itching,characterofmenstrualperiods,contraceptivemethod

Males:Erectiledysfunction,lesions,contraceptivemethod

Nervoussystem Seizures,tremors,weakness,alteredsensations,difficultiesinspeech, incoordination

Musculoskeletalsystem Pain,trauma,tenderness,swelling,decreasedrangeofmotion

Neuropsychiatricsystem Changesinmood(anxiety,depression),changesinmemory,difficultysleeping,difficultyconcentrating

Endocrinesystem Polyuria,polydipsia,polyphagia,intolerancetoheatorcold

Peripheralvascularsystem Varicoseveins,legcramping,edema


tabLe 2.3 sequence of the physical examination

• Vitalsigns

• Generalappearance

• Head,eyes,ears,nose,andthroat(HEENT)

• Neck

• Chest(lungsandbreasts)

• Heart

• Abdomen

• Genitourinarysystem

• Rectalexamination

• Extremities

• Lymphnodes

• Neurologicexamination

• Skin

however, themost current and complete results are usually located in a computerdatabase.Additionally,practitioners’H&Psmayincludedocumentationofinitiallabresults.However, it is important toviewtheactualresults foroneself,because it iseasy for an error in transcription to occur. Similarly, practitionersmay omit someresults fromtheH&Pdocumentation for the sakeofbrevity; again,viewingactualresultsonacomputersystemwillpermitacompletereviewofdata.

diagnostic test results

InitialresultsofdiagnostictestingaredocumentedwithintheH&Paswell.Suchresultsmayincludeelectrocardiograms,echocardiograms,ultrasounds,computedtomography(CT)scans,magneticresonanceimaging(MRI)scans,x-rays,andsoon.Becausethesetestsrequireinterpretation,oftenbyaseparatephysician(e.g.,radiologist,cardiologist),dictations of their results are often available on a computer system and/ormay beprintedforplacementinthepaperchart.


problem List

Theproblem listnotes,indecreasingorderofpriority,theissuesthatrequireman-agementintheindividualpatient.Thenumberoneneedonthelist istheworkingdiagnosisthatmatchesthesignsandsymptomswithwhichthepatienthaspresented.Forexample,apatientpresentingwithchestpainwhoisdiagnosedwithaSTsegmentelevationmyocardial infarctionwillhave“STEMI” listedas thehealthcareneedofhighestpriorityonthelist.Alternatively,apatientpresentingtoacommunityphar-macy with a prescription for an antihypertensive medication for newly diagnosedhypertensionmayhave“initialtreatmentforHTN”asthenumberoneneedonthelist.Subsequenthealthcareneedsorproblemsarelistedindescendingorderofprior-ityorseverity;thesetypicallyincludechronicmedicalconditionscontainedwithinthePMH,abuseofsubstancesnotedinthesocialhistory,drug-relatedproblemsidentifiedwithcurrentorpastmedications,laboratoryordiagnostictestabnormalitiesidentifieduponadmission,andsoon.Numerouspractitionerswilldocumentproblemlistswithinthemedicalrecord.

Foraninpatient,theadmittingpractitioner,nurse,pharmacist,nutritionist,respira-torytherapist,andphysicaltherapistmayeachhavetheirownprioritizedlistofneedswithin thechart,overlapping in somewaysandunique inothers.Fromthese, it ispossibletocreateacomprehensivelistthataddressesalloftheissuesathand.Foranoutpatient,theattendingpractitionermaydevelopalistattheendofhisorhernote,addressingthoseissuesofhighestpriority.Forbothinpatientsandoutpatients,prac-titionerswilloftendocumenttheirplansforeachneed,includingadifferentialdiag-nosis,treatmentsbeingconsideredoradministered,andaplanforpatienteducation.Regardlessof location, it is important tonote that theproblem list isdynamic.

It can change fromday today for an inpatient or fromvisit to visit for anoutpa-tient.Thisisanticipatedbecausepatients’diagnosesandindividualcharacteristicscanchangequickly, especially in theacute setting.Later in this chapterwewill reviewhowtodevelopacomprehensiveproblemlistthatincludesdrug-relatedproblems.

clinical notes

Theinpatientpaperchartoftengetsthickwiththemanytypesofclinicalnoteswrit-tenbythenumerouspractitionerscaringforthepatient.TheresidentandattendingphysicianwillwritedailyprogressnotesthatdocumentanupdatedandabbreviatedH&P,problemlist,andplan.Otherspecialists(e.g.,cardiologist,gastroenterologist)willalsodocumenttheirfindingsindailyprogressnotesfollowingtheirinitialconsul-tationnotes.Forexample,apatientwithahistoryofatrialfibrillationandcoronary


arterydiseasemayhaveacardiologistfollowinghiscase;theimpressionsofthisspe-cialistarecommunicatedtothepatientcareteamviadailyprogressnotesfocusingonthepatient’scardiacissues.Nursesmaintaintheirownclinicalnoteswithinthecomputersystemoronabed-

sidechart.Oftentheseincludedocumentationofvitalsigns,painassessments,patientactivities (e.g.,outofbed tochair,bathroomvisits), andquantityof fluidapatientingestsandexcretes(e.g.,insandouts).Additionally,ifthereisachangeincare,suchasmovementfromtheintensivecareunit(ICU)tothegeneralmedicalfloor,transfernotesarewrittenbythephysiciansandnursestosmooththetransitionbetweencareteams.Similarly,ifapractitionerisnolongergoingtocareforapatient,forexample,duetoavacationortimeawayfromthehospital,heorshewillwriteanoff-servicenote toassist the successorpractitioner in the transitionofcare.Allof thesenotesareusefulsummariesofthediagnosticmethodsusedandtreatmentprovidedpriortotheoccurrenceofthetransfer.Lastly,adischargesummaryprovidesasnapshotofthepatient’shospitalcourse,

includingahealthcareneedslistandtreatmentsprovided,aswellasaplanforfuturefollow-upandalistofdischargemedications.Thisiscombinedwithdischargepaper-workfromthenursingandpharmacystaffthatincludeseducationalinformationpro-videdtothepatient,suchasmedicationleafletsandpostdischargeinstructions(e.g.,woundcaredirections,dateoffollow-upappointmentwithprimarycarephysician).Outpatientmedicalrecordstypicallyincludenotesfromallofficevisits.Addition-

ally,anyclinicalnotesfromhospitalizationsareoftencopiedandplacedinthepaperchartorarescannedandplacedintheelectronicmedicalrecordtopermitcontinuityofcare.

treatment notes

Treatmentnotesareutilizedmostfrequentlyintheinpatientsetting.Treatmentnotesincludemedicationorders,medicationadministrationrecords (MARs),documenta-tionofsurgicalprocedures,anddocumentationofservicessuchasradiationtherapy,physicaltherapy,occupationaltherapy,respiratorytherapy,andnutrition.Alloftheseareasof the chart are important to review,because eachprovidesdetails regardingtheexecutionof thepatient’s treatmentplan.Medicationorderscanbe transcribedbythepractitionerontoapaperorderform;thesecanthenbefaxed,scanned,orcopiedandsenttothepharmacyforprocessingandfilling.Alternatively,thepractitionermayenter themedicationordersdirectly into the computer systemusing computerizedprescriberorder entry (CPOE,discussedbelow); theorders are then reviewedand


processedbythepharmacist.Theorderssectionofthechartmayalsocontainordersfromotherpractitioners, includingphysicalandoccupationaltherapists,respiratorytherapists,andnutritionists.Rationalefortheseorderscanbefoundinthetreatmentnotessectionforeachofthesepractitioners.Thisprovidesinsightastothepatient’sentireproblemlist,becausethesepractitionersplayimportantrolesinmanagingvari-oushealthcareneedsontheindividualpatient’slist.Medication administration by nurses and other practitioners (e.g., respiratory

therapists,physical therapists) isdocumentedviaMARs.Thesecanbepaper-basedorelectronic(eMAR)andpermitonetoviewthedatesandtimesofallmedicationsadministeredtothepatientaswellasdocumentationofmissingorrefuseddoses.

electronic and paper-based data collection systems

Records of patient information, including the official medical record, can exist ineitherelectronicorpaper-basedformats,oracombinationofboth.Regardlessoftheformataninstitutionisusing,thetypesofpatientdataanddocumentationavailabletypically include thecomponents thathavebeendescribedpreviously in this chap-ter.As technology continues to advance in thehealthcare arena, the capabilitiesofelectronicmedicalrecordformatscontinuetoexpand,includingprovidingimprovedaccessibilityofpatientdataviahandheldmobiledevices.Electronicmedicalrecordsystemsvarybyvendorandinstitutionandcaninclude

the components described previously. As with paper-based formats, the HealthInsurancePortabilityandAccountabilityAct (HIPAA)SecurityRuleencompassesprotected health information stored in electronic formats; this requires health-care organizations to ensure the confidentiality and security of this information.3

CPOE technology allows the provider to enter an order for a patient; the ordercanthenbeviewedandconfirmedinthesameorarelatedelectronicsystem.Forexample,aphysiciancould inputamedicationorder fora specificpatient intoanelectronicsystemandthentheordercouldbecommunicatedelectronicallytothepharmacist. Figure 2.1 showsanexampleofacomputer screenshot fromcurrentCPOEtechnology.With this system,eachof thepatient’sproviders canview thepatient’scurrentmedications,aswellasanydiscontinuedmedications.Thisprocessmayhelptoreduceoreliminateerrorsthatareassociatedwithpaper-basedsystems,includingerrorsattributabletopoorproviderhandwriting.4 Additionally,decision-support tools embedded within the electronic systemmay offer additional assis-tancetoproviders.Often,thecomputerizedsystemthathousestheCPOEincludesadditionalfileswithinapatient’smedicalrecordtosupportelectronicfilingofdic-tatedpatientcarenotes, radiologicand laboratorydata,andmore.Anexampleof


electroniclaboratoryresultdataisshowninFigure 2.2.Itisimportanttonotethatalthoughaninstitutionmayutilizeanelectronicsystem,notallofthedataavailablein that institutionmay be recorded electronically; data that are only recorded inpaperformatdespitethepresenceofanelectronicsystemshouldbeidentified.Inadditiontomaintainingthepatient’spermanentrecord,inpatientsystemsmay

recordmedicationsas theyareadministered to thepatient, therebymaintaininganinteractivepatienteMAR.Figure 2.3presentsascreenshotofasampleeMAR.Intheoutpatientsetting,similartechnologiescanfacilitatesharingofpatientandelectronictransfers of medication prescription requests. For example, prescription requests,alongwithsupportivedata,maybetransferredelectronicallytoapharmacy.Limita-tions to implementationof such software inhealthcare institutions tend to includecost, workflow support, training, and organizational factors.5 Paper-based recordsshouldofferthesamedatarecordedastheelectronicmedicalrecord.Patientsarepermittedtoreceivecopiesoftheirmedicalrecords,buttheproce-

duresforthismustbesetforthbythehealthcareinstitutioninaccordancewithstate

figure 2.1 Exampleofacomputerizedprescriberorderentry(CPOE)system.


and federal law.Typically, patients can review theirmedical record in themedicalrecordsdepartmentoftheinstitutionorreceiveresultsoflaboratoryanddiagnostictestingfromtheirphysician.3

Pharmacistscanfollowanumberofstepstopreventimproperdisclosureofmedi-calinformation,therebypreventinglegalconsequencesandfines:

• Providers shouldkeepclipboards and folders containingpatient informationwiththematalltimesand/orinasecurearea(e.g.,inalockedfileinthephar-macydepartment).

• Providersshouldfollowthe institution’spolicies forretaininganddiscardinghealthinformation.Thismayinvolvestorageofinformationinlockedcabinetsandshreddingmaterialswhentheyarenolongerneeded.

• Providersshouldsignoffofthecomputersystemwhentheyarefinishedusingit.Applicationswithpatientinformationshouldneverbeleftopen,eveniftheproviderjustgetsupforaminutetoansweraphoneortousetherestroom.

figure 2.2 Exampleoflaboratorydatastoredinanelectronicsystem.


systematic apprOach tO data cOLLectiOn

Consideringtheoftenlargeamountofdataavailableinthepatient’smedicalrecord,pharmacists must use a systematic approach to review patient data. This processinvolvesreviewingpertinentandtimelycomponentsofthepatient’smedicalrecord,theMAR,andotherrelevantdata,andthencompilingthisdata.Datamaybetran-scribedontoawrittenorelectronicdatacollectionformandcanbeusedbythephar-macisttomaintainanaccurate,consistent,andorganizedviewofthepatientforthepurposesofdevelopingafocusedpharmacy-relatedassessmentandplanofcare.Dataareoftenstreamlinedtomakeiteasiertoprovidepharmaceuticalcaretothe

patient;however, thedatamustbecomprehensiveenoughtoensure that thephar-macistmaintainsacompleteunderstandingofthepatient.Datamaybefocusedonasinglevisitintheoutpatientorurgentcaresettingoronasingledayorvisitduringaninpatienthospitalstayandthenupdateddaily.Asystematicdatacollectionprocesscanhelpthepharmaciststayorganizedfrompatienttopatient,daytoday.

figure 2.3 Exampleofanelectronicmedicationadministrationrecord(eMAR).

systematic approach to data collection 49

Datacollectionmethodsmayvarybetweenpharmacistsorclinicalsites;however,they share the commongoal of allowing a consistent reviewof a single patient ormultiplepatientsatonce.Thisapproachusuallyinvolvestheuseofapaper-basedorelectronicformthathasenoughspacetoincludealloftherelevantmaterialthatthepharmacistmayneedtocollect.Theseformsareoftendevelopedortailoredtomeettheneedsofaspecificpharmacistwithadesignatedsetofpatientcareresponsibilitiesandmaybeformattedtomirrortheorderinwhichthepharmacistwilleithercollectorinterpretthedata.The benefits of a systematic approach are numerous. First, it allows the phar-

macisttoroutinelyorganizeinformationpertinenttothepharmaceuticalcareofthepatient in a consistentmanner.Second, systematicdata collection allows thephar-macist tomaintainaprocessduringwhichpotentialdrug-relatedproblemsmaybeevaluated.Third,thisapproachallowsforeaseofpatientcare“pass-off”shouldthepharmacist transfercareofapatient toanotherpharmacist.Additionally, thephar-macist’scollecteddatamaybecomearesource forreportingonpatientcareduringrounds, facilitating discussion with other healthcare practitioners, or documentingclinicalinterventions.

initiating the systematic approach to data collection

Aprimarygoalofsystematicallycollectingdatafromthepatientrecordshouldbetokeeptheprocesssimpleyetrelevantandcomprehensiveenoughforapharmacist’sneeds.Akeyinthisprocessisnottoovercollectdatabecauseitisavailable,buttobesurethatthereisauseandareasonforeachtypeofdatabeingcollected.Becausethismaybecomearoutineactivityasapartofpatientcare,efficiencyandconsistencyincollectionofdatabecomeimportant.Forexample,apharmacistmayhavemanypatientsunderhisorher immediatecareandmayneed toreviewdataoneachofthesepatients.Timing of patient data collection usually follows a three-point approach: a

preencounterassessment,amid-encounterassessment,andapostencounterassess-ment. Regardless of the setting, the role of the pharmacist in the preencounterassessment is often to gather data relevant to the care of the patient for a giventask(e.g.,clinicvisit,patientcarerounds),andthisistypicallyconductedpriortomeetingwiththepatientorproviderteam.Datacanthenbeupdatedoraugmentedduringthemid-assessmentencounterwiththepatientbasedonadditionalfindingsorthepatientinterview.Finally,monitoringandfollow-upofneworchangeddatashouldoccur,andthedatacollectionformupdatedaccordinglyinthepostencoun-terassessment.


types of systematic data collection forms

Asdiscussedpreviously,datacollectionformsareoftenindividualizedtoagivenphar-macistorroleinaclinicalsetting.AnexampleofadatacollectionformisshowninFigure 2.4;however, this formservesonlyasa startingpoint todemonstrate thatformsmaybe customizedand include space fordata. Individual formswillbe tai-loredtomeet theneedsof thepractitionerandwillvarybasedonthepractitionerorsituation.Dataontheformthatisnotwithinthescopeofpracticeforthephar-macisttoobtainmaybecollectedfromthemedicalrecord,asdescribedpreviously.

figure 2.4 Samplepharmacistdatacollectionform.

Age: Allergies:Height:Weight:

Chief complaint:

History of present illness:

Past medical history:

Family history:

Home medication anddose:

Route: Frequency: Last dose (date/time):

Social history:

Physical exam:

ROS:

Laboratory data and serum concentrations:

Current medicationand dose:

Problem list: Patient plan:

Route: Frequency: Indication:

systematic approach to data collection 51

Datacollectionformsareheavilyinfluencedbythemannerinwhichthepharmacistislikelytoassessthepatient;therefore,theformatanddatavarybasedonthetypeofprac-ticesettingorproviderservice.Severalfactorsmayplayaguidingroleinthedecisiontouseaparticulartypeofdatacollectionform,includingtheclinicalsetting(e.g.,inpatientoroutpatient),theroleofthepatientcareteam(e.g.,primaryteamorconsultservice),orthespecifictaskpresentedtothepharmacist(e.g.,assessmentofafocusedproblemorageneralizedworkupofthepatient).Regardlessofthenuancesamongdatacollectionforms,applyingasystematicmethodofdatacollectionfromapatient’smedicalrecordiskeytoensuringconsistencyintheapproach,assessment,andplanforeachpatient.

pharmacy-reLated cOmpOnents Of the patient medicaL recOrd

A critical skill for the efficient pharmacist is to review the data with several keypharmacy-relatedaspectsinmind;thiswillpermitconcisedatacollectionwhileprovidingthe pharmacist with adequate information to develop recommendations to optimizepharmacotherapy.Depending upon the patient care responsibilities of the individualpharmacist, thepertinentpharmacy-relatedcomponentsofapatient’s chartmayvary.Forexample,aninfectiousdiseasesclinicalpharmacistmaydiverightintothecharttoseekoutantibioticordersandlaboratorydataforserumdrugconcentrationsandrenalfunctionassessments,whereasacardiologypharmacyspecialistmayinitiallysearchforbloodpressurevaluesfromthephysicalexaminationinordertoassesstheeffectivenessofapatient’santihypertensivedrugregimen.Regardlessofspecialtyorfocus,severalgeneralpharmacy-relatedcomponentsarecontainedwithineachportionofthemedicalrecord.

medical history

Themedicalhistory(H&P)isakeyareaforidentifyingdrug-relatedproblems,whichwillbediscussedatlengthinthefinalsectionofthischapter.Thus,themajorityofinformationcontainedwithintheH&Pisvaluableindevelopinganassessmentandplanfor interventionstooptimizepharmacotherapy.Thepharmacistmayfinddatalackinginsomeareas,whichwillrequireclarificationviaadditionalpatientinterview-ing.Forexample,apatient’schartmayindicateanallergytopenicillin,butthespecificreactionnotbeidentified.Thepharmacistcanthenquestionthepatienttoobtainanddocumentthisimportantpieceofinformation.Similarly,componentsofthemedica-tionhistorymaynotbecomplete.Forexample,theH&Pmaynoteamedicationlistwithoutdosesorfrequencyofadministration.Thepharmacistcanquestionthepatient


andevencontactthepatient’spharmacytoobtainthisinformationfordocumentationinthechartandonthepharmacist’sdatacollectionform.Additionally,physicalfindingsmaybegermanetoassessingthepatient’sresponse

tomedicationsthatareeithermissingornotdocumentedinthechart.Theserequirethepharmacisttoperformtheappropriateassessmenttechniquetoobtainanddocu-ment the finding.Forexample, thephysicalexaminationofapatientwhopresentsto the hospitalwith nausea and vomiting resulting fromphenytoin toxicity shouldnotethepresenceorabsenceofnystagmus,afindingassociatedwithsupratherapeu-ticserumconcentrationsofthedrug.Ifthisinformationisnotfoundinthemedicalrecord,thepharmacistshouldperformtheappropriateassessment(inthiscase,theHtesttoassessfornystagmus)anddocumentthefindingaccordingly.ThroughouttheH&P,thepharmacistcanidentifypertinentpositiveandnega-

tive components that are key to the development of an assessment and plan.ThisbecomesespeciallyimportantwhengatheringdatafromtheHPI,ROS,andPE.Theimportanceofpertinentpositivescanbeeasilyrationalized,whilepertinentnegativesarenotsoobvious.Forexample,ifthefamilyhistoryofa39-year-oldmanpresentingtotheemergencydepartmentwithamyocardialinfarctionindicatesnofamilyhistoryofcoronaryarterydisease, it isapertinentnegativefacttonoteonthedatacollec-tionform,becauseitmightbeexpectedthatsomeoneinthepatient’s familywouldhavepreexistingcardiacdisease.Anotherexamplewouldbeapatientpresentingwithpneumoniawhohasnoshortnessofbreath(SOB).Thepharmacistshoulddocument“noSOB”intheROSofthispatient,becauseitisapertinentfindingforthispatient.AlargemajorityoftheH&Pisrelevanttothepharmacist’sdatacollection.

Laboratory and diagnostic test results

Inthelabsection,pharmacistscanfocusonanumberofpharmacy-relateddatapoints,including labs reflectingeffectsofdisease states andmedicationsonorgan systems(e.g.,serumcreatinine,liverfunctiontests,CBC,urinalysis),serumdrugconcentra-tions(e.g.,vancomycin,phenytoin,digoxin),andcultures.Again,pertinentnegativevaluesareimportanttodocument,becausesomepatientsmayhavesomeunexpectedlynormallabs(e.g.,normalliverfunctiontestsinapatientwithahistoryofliverdisease).Diagnostic test results become important for the pharmacist to gather in order tounderstandthestatusofthepatient’svarioushealthcareneeds.Again,normalresultsofdiagnostictestscanbejustasvaluableasabnormalresults(e.g.,normalelectrocar-diograminapatientwithchestpain)andthusshouldberecordedbythepharmacistonthedatacollectionform.

pharmacy-related components of the patient medical record 53

clinical and treatment notes

As discussed previously, these areas contain a large amount of information.Manypiecesofdataherecanbeconsideredkeypharmacy-relatedcomponents,including:

• Updatestoproblemlists,includingneworchangeddiagnoses• Dailyupdatesregardingthepatient’sROSandPE,includingdailyvitalsigns,insandouts,etc.

• Nursingnotes,includingupdatedvitalsigns,insandouts,painscores,reasonsforrefusedordelayedmedicationadministration,intravenouslinesitestatus,dailybodyweights,etc.

• Inputfromspecialistsregardingthestatusofvariousproblemsonthepatient’slist• Prescriber rationale for changing a medication regimen, dosage, and/orduration

• MAR/eMAR,includingconfirmationthatscheduledmedicationswereadmin-istered,timingofmedications(e.g.,vancomycin,andaminoglycosides),timingof asneededmedication administration (e.g., analgesics, antipyretics, slidingscaleinsulin),orfingerstickbloodglucoseresults

navigating chOppy Waters: What tO dO if infOrmatiOn is missing and/Or mispLaced

Oneofthegreatestchallengesingatheringinformationfromapatient’schartisactu-allylocatingalloftherequireddata.Itiscriticaltocollectallpertinentinformationfromthemedicalrecordinordertocreateathoroughandcompleteassessment,prob-lemlist,andplanforanindividualpatient.Itcanbefrustratingtosearchthechartforapieceofinformationandnotfinditwhereitshouldlikelybe.Severalissuescanarisewhennavigatingthechoppywatersofthemedicalrecord.

missing details

Details are often missed during the documentation of the PMH. For example,apatientwhoisHIVpositiveshouldhavetheyearofdiagnosisandthemostrecentviral load andCD4T-cell counts listed.The chart of a patient with diabetes, forexample,shouldhavethetypeofdiabetesdocumented(i.e.,type1ortype2)aswellasanyassociatedcomplications(e.g.,diabeticretinopathy,neuropathy,nephropathy).Iftheseclarifyingdetailsaremissing,theycanoftenbelocatedinotherareasofthechart, includingH&Psfrompreviousadmissionsorvisits,previouslabstudies,andevenfrominterviewingthepatient.


information in the Wrong Location on the chart

Informationmaybelocatedinthewrongsectionofthechart.Thismostcommonlyseemstooccurwiththereviewofsystemsandthephysicalexam.ItisimportanttorememberthattheROSisnotthePE;inexperiencedpractitionersmayinadvertentlydocumentaphysicalfindingintheROSsection,orviceversa.Forexample,shortnessofbreathmaybedocumented in thepulmonarypartof thePE,when it shouldbelocatedintherespiratorysystempartoftheROS,becauseitisasymptomsubjectivelyperceived and reported by the patient.This occasionally occurswithFH and SH;inexperienced providersmay place information regardingmarital status in theFHsection,forexample.Whennavigatingapatient’schart,thereadermustbeawareofthepotentialformisclassificationofdataandensurethatthedataareproperlyplacedonthedatacollectionsheet.

conflicting information

ConflictinginformationmaybecomeanissuewhenmultiplepractitionersperformH&Ps on the same patient. For example, thePE performed by themedical stu-dentmaynotethatthepatient’sbreathsoundsarecleartoauscultationbilaterally,whereastheresidentphysicianhasdocumentedralesandrhonchiintheleftlowerlobeofthelung.Clarificationofconflictinginformationmayrequirereviewingfur-therinformationinthechartinadditiontospeakingwiththeteamofpractitionerstakingcareof thepatient.Additionally, thepharmacistmay interview thepatientandperformaphysicalassessmentofthepatienttodeterminearesolutionfortheconflictinginformation.

Locating all of the information

Occasionally,itmaybedifficulttoobtainapatient’sinpatientpaperchartbecauseitisbeingusedbyanotherpractitionerorbecauseit issentwiththepatientwhenheorsheleavesthemedicalfloorfordiagnostictesting(e.g.,x-ray)orprocedures(e.g.,surgery).Whenthisoccurs,informationgatheringcanbeginwithusingtheelectronicmedicalrecordsystemtogatherlaboratoryanddictatedinformation.Anyinforma-tion that cannotbeobtained in thismannercan thenbe followeduponwhen thepaperchartbecomesavailable.Additionally,theremaybeahighdemandforcomputerterminals on nursing floors or in a cramped ambulatory care clinic setting.Again,patienceiskey;itmaybebesttostartwithareviewofthepapermedicalchartfirstandthenreviewtheelectronicmedicalinformationonceacomputerbecomesavailable.Alternatively,findingaseparate,securelocationwithadditionalterminals,including

navigating choppy Waters: What to do if information is missing and/or misplaced 55

adifferentmedicalfloororamedicallibrary,willpermitreviewofelectronicinforma-tioninatimelymanner.Itmayalsobehelpfultoperformreviewsofmedicalrecordsat“offhours”onthepatientcarefloor,suchasveryearlyorlatetimesofthedayorduringresidentphysicians’mandatoryconferences,becausethedemandforchartsandcomputersisoftenloweratthesetimes.Oncegatheredonadatacollectionsheet,thepharmacistcansynthesizeallofthekeypiecesofinformationinthemedicalcharttodevelopacomprehensivehealthcareneedslist.

synthesizing patient infOrmatiOn: deveLOping a prObLem List

Onceapatient’sinformationisgatheredfromallofthenecessarysources,thepharma-cistcancreateacomprehensivelistofpharmacy-relatedhealthcareneedsthatencom-passesapatient’sdiseasestates,drug-relatedproblems,and/orpreventivemeasures.Thisproblemlistshouldbeprioritized,withthemostclinicallysignificantissueslistedfirst.Forexample,amalesmokerpresentingtotheemergencydepartmentcomplain-ing of shortness of breathwho is diagnosedwith community-acquired pneumonia(CAP) shouldhavepharmacy-relatedproblemsassociatedwith“CAP” listedas thenumberonehealthcareneedonhislist,whilesmokingcessationwillbelowerinpri-orityonthelist.Creationofthislistcanbechallenging;however,withanorganizedsystematicapproach,itcanbedoneefficientlyandeffectively.

disease states

Oftenreferredtoasmedical problems,thediseasestatesapatienthasshouldbeincludedinthehealthcareneedslist.Theseareoftenderivedfromacutediagnoses,asinthecaseofapatientinthehospitalsetting,andfromthePMH.Practitionerssuchasphy-sicians,physicianassistants, andnursepractitionersare theprimarycaregiverswhodiagnoseanddocumentthesediseasestatesinthemedicalrecord.Examplesofdiseasestatesincludehypertension,hyperlipidemia,otitismedia,andCAP.

drug-related problems

Drug-related problems (Drps) are events or issues surrounding drug therapythat actuallyormaypotentially interferewithapatient’s ability to receive anopti-maltherapeuticoutcome.6 DRPsareseparateentitiesfromapatient’sspecificdiseasestate.Inpractice,thepharmacistcanhelpdeterminethepresenceofactualorpoten-tialDRPs.AnyobservedDRPsshouldbeaddedtothepatient’shealthcareneedslistandultimatelyserveasthefoundationforthepharmacist’sassessmentofthepatient.


EachDRPcanbeconsideredasanoverallproblem,butmaybeexpandedasspecificproblemsareconsidered.SeveralDRPshavebeendescribed:6–10

• Indication lacking a drug.Eachdiagnosisorindicationshouldbereviewedtodeterminethepresenceorabsenceofappropriatedrugtherapy, includingsynergisticorprophylacticdrug therapy. Indications thatneeddrug therapy,yet are lacking in any or complete therapy, should be evaluated further. AnexampleofthisDRPincludesapatientwithahistoryofcoronaryarterydiseaseandhyperlipidemiawhodoesnothaveanymedicationsprescribedforhyper-lipidemia.ThisDRPmayalsobeobservedinapatientwithgeneralizedanxi-etydisorderwhohasnotreceivedanantianxietymedication(e.g.,aselectiveserotonin-reuptakeinhibitor,benzodiazepine,etc.).

• Indication with incorrect drug. Each diagnosis or indication should bereviewedtodetermineifthetherapyassociatedwithitiseffectiveorcorrect,notonlywiththedrugitself,butalsowiththerouteofadministration.Often,thisDRPwarrantsreevaluationasadiseaseprogresses,patienttoleranceincreases,orefficacyisnotobserved.AnexampleofthistypeofDRPwouldbeapatienttreatedwithintravenousvancomycinforClostridium difficile colitis.Therouteofadministrationforvancomycinforthisindicationshouldbeoral,becausetheintravenousrouteisineffective.

• Wrong dosage.ThisDRPincorporatesadrugdosethatmaybetoohighortoolow.Bothinstancescanaltertheefficacyandsafetyofatherapeuticagentand requires evaluation.Additionally, dose frequency and duration shouldbeevaluated.Forexample,apatientwhoisHIVpositiveandwhoreceivesatazanavir200mgdailyasacomponentofherantiretroviraldrugregimenwouldhavethisDRPonherproblemlist,becausethisdoseofatazanaviristoolow.

• Inappropriately receiving drug. This DRP may alternately be describedas thepatienthavingproblemswithcomplianceoradherencetoaparticularmedicationorregimen.However,thisDRPmayalsopertaintopatientmisun-derstandingabouthowaspecificdrugshouldbetakenorlackofavailabilityoftheagent,perhapsduetomanufacturingavailabilityissuesorpatientfinancialissues.AnexampleofthisDRPwouldbeapatientwhomisses2weeksofhistreatmentregimenforhepatitisCinfectionduetonotreceivingitinthemailfromhismailorderpharmacy.

• adverse reaction to a drug. Adverse drug reactions (ADRs) should beassessed.Ifanoffendingagentisfound,itmaybediscontinued.Forexample,if apatient receivingampicillinon the inpatient floorbreaksout intoa rash

synthesizing patient information: developing a problem List 57

followingtreatmentinitiation,shemaybeexperiencinganADRandshouldbeappropriatelyevaluated.

• Drug interaction. Drug therapy should be evaluated as a whole for eachpatient,andthepresenceofpotentialoractualinteractionswithdrugtherapyshouldbeconsideredandevaluated.Thisisespeciallyimportanttoassesswhenapatientisonmedicationswithahighpropensityfordruginteractions,asinthecaseofapatientreceivingrifampinfortreatmentoftuberculosis.

• Drug lacking indication.Alldrugsshouldbedirectlyconnectedtoaparticularindication.Ifanindicationisnotpresentorisnolongerpresentforaspecificdrug,thepatientmayneedtobeweanedofftheagentordiscontinueit.Forexample,apatientreceivinghydrochlorothiazidewhodoesnothavehyperten-siononhisproblemlistandwhodenieshavinghighbloodpressureshouldhavethisDRPdocumentedonhisproblemlist.

DRPscanvary innatureandoftenarise fromthediseasestatespresentonthepatient’sproblemlist.ItiseasytobecomeoverwhelmedwhentryingtoidentifyalloftheDRPsforanindividualpatient.Thus,followinganorganized,stepwiseprocessiskeytoensuringthatallDRPsareidentifiedandprioritizedproperly.9 Thisorganizedapproachissummarizedintable 2.4.Step4inTable2.4permitsthepharmacisttoquicklyrecognizeifaDRPexistswithaparticularmedication.Iftheanswertoanyofthefirstfourquestionsis“no”oriftheanswertothelastquestionis“yes,”furtherinvestigationtoidentifyDRPsisnecessary.OnceallDRPsareidentified,theycanbeprioritizedandmergedintotheproblemlistwiththepatient’sdiseasestates.10

For example, consider the following patient encounter. An otherwise healthypatientarrivesattheclinicaftercompletingatrialoflifestylechangesforhisrecentdiagnosisofhypertension.Atthiscurrentvisit,thepatient’sbloodpressureremainselevated,and,alongwiththeprescribingpractitioner,thepharmacistagreestohelpdevelop a medication plan for this patient. The pharmacist reviews all necessarydata, including the patient’s medical history, allergies, and contraindications, cur-renthypertensionguidelines,andappropriatedruginformation,andsuggeststotheprescriberthatsheinitiateanantihypertensivemedicationatanappropriatestartingdoseandfrequency.Thepharmacistdocumentsthepatient’sDRPas“indicationlack-ingdrug.”Notethatthisisdifferentfromthephysician-diagnosedmedicalproblem,whichwouldbe“hypertension.”Atfollow-upvisitswiththispatient,thepharmacistwilllikelyassessthepatientforadditionalpotentialDRPs,includingpotentialnonad-herence,druginteractions,andthepresenceofadversedrugreactions.Ifanyofthesewereobservedatthefollow-upvisit,thepharmacistcouldworkwiththeprescribingpractitionertoprioritizeexistingDRPsandcreateaplanforeachproblem.


preventive measures

Healthcareprofessionalsadditionallytakeactiontopreventillness.Thisoftentakestheformofhealthmaintenanceactions,suchasadministrationofroutineimmuniza-tions(e.g.,influenza,pneumococcal),andpatienteducation,suchassmokingcessationcounseling.Alsoincludedinthiscategoryareprophylacticmeasuresagainstacuteill-ness,includingdeepveinthrombosisprophylaxisandstressulcerprophylaxis,eachof

tabLe 2.4 steps to recognizing drps

1. KnowwhattheDRPsare.Itmaybehelpfultokeepalistinfrontofyouuntilyoufeelmorecomfortablewiththem.

2.GatherpatientdatafromtheH&Pandnotes.Useanorganizeddatacollectionsheetforrecordingallinformationrequired,includingadraftofthepatient’sproblemlist.

3. Isolateeachproblemontheproblemlistandidentifythemedicationsbeingadministeredforeachproblem.Creatingatablelikethatshownbelowmaybehelpful:

problem List (in descending order of priority)

medications patient is receiving for each problem (drug, dose, route of administration, frequency)

Adruginformationresourcemayassistwiththisstep.

4. Screeneachmedicationonthepatient’slistwiththefollowingquestions:

• Isittherightdrugfortheindication?

• Isittherightdose?

• Isthedrugworking?

• Isthepatienttakingthedrugappropriately?

• IsthedrugcausingADRsordruginteractions?

Iftheanswertoanyofthefirstfourquestionsis“no,”oriftheanswertothelastquestionis“yes,”furtherinvestigationtoidentifyDRPsisnecessary.

5.OncealltheDRPsareidentified,theycanbeintegratedintotheoverallproblemlistprioritizedinorderofmostclinicallysignificanttoleastclinicallysignificant.

Source: KaneMP,BricelandLL,HamiltonRA.Solvingdrug-relatedproblems.US Pharm.1995;20:55–74.

synthesizing patient information: developing a problem List 59

whichmaybenecessaryinat-riskhospitalizedpatients.Oftentimes,thesepreventivemeasuresarelowerinprioritythanmostofthediseasestatesandDRPsonapatient’sproblemlist;however,itisimportantthattheyareincluded.

case study

Considerthefollowingcasestudyandthepharmacist’sdevelopmentofanappropriateproblemlist.

CC: “Iamsodizzyandconfused!”

HPI: ZZ,a40-year-oldman,isbroughttotheemergencydepartmentbyhiswifeonaDecembermorning.ZZcomplainsofincreasingdizziness,lethargy,andconfusionoverthepast3days.Healsodescribesdiplopiaforthepastday.ZZ’swifenotesthatZZcanbarelywalkinastraightline.

PMH:Seizured/ox15years,HTN

FH: NC

SH: Doesnotsmoke,noETOHuse,livesathomewithwife,worksinconstructionoperatingabulldozer

ALL: PCN(hives)

Meds PTA: Phenytoin300mgPO3timesdaily;HCTZ25mgPOdaily;ibuprofen800mgPO6timesdailyasneededforheadaches

ROS:+fordizziness,confusion,lethargy,diplopia,nausea;–forvomiting,diarrhea

PE:

VS:110/70,98.5,99,14,67inchestall,60kg

HEENT:PERRLA,+nystagmus,MMM

Neck:Supple,noJVD,noLAD

Lungs:CTAbilaterally

Heart:S1S2,nom/r/g

Abd:NTND,+BS

Neuro:+Romberg,A&Ox1,CNassessmentnotperformedduetopatient’sinabilitytofollowdirections

Rectal:Deferred

LAB:Na138;K3.7;Cl100;CO225;BUN10;SCr1.1;Glu94;AST19;ALT20;Tbili1.0;albumin4.0;phenytoin35mg/L;CBC:pending


tabLe 2.5 problem List

priority problem List type of problem

1 Adversedrugreactiontophenytoinsecondarytosupratherapeuticserumconcentration

Drug-relatedproblem(adversedrugreaction/wrongdosage)

2 Seizuredisorder Disease state

3 Overdosageofibuprofenforheadache Drug-relatedproblem(wrongdosage)

4 Hypertension Disease state

5 Influenzaimmunization Preventativemeasure

BasedonthepertinentinformationfromtheH&PandreviewingtheinformationcloselyforDRPsusingthemethoddescribedinTable2.4,thepharmacistcaringforZZhasdevelopedaproblemlistdocumentedinorderofpriorityfrommostclinicallysignificanttolessclinicallysignificant(table 2.5).

chapter summary

Althoughitiseasytobecomeoverwhelmedbythevoluminousamountofinforma-tionavailableinthepatient’smedicalrecord,itisimportanttogainperspectiveonthecomponentsofthemedicalrecord,whetheritisavailableelectronically,onpaper,orboth.Itisimportanttodevelopastrategyforcollectingdataandidentifyingthepiecesofinformationthatarecriticaltothecreationofaproblemlist.Additionally,thestep-wiseapproachtodevelopingaproblemlistthatincludesthedrug-relatedproblemspresentedinthischapterwillallowyoutoefficientlyprioritizetheissuesthatimpactyourpatient.Thiscanthenbetakentothenextlevelthroughprovisionofpharma-cotherapeuticrecommendationstotheprescriberinordertooptimizedrugtherapyandoutcomes.

Take-Home Messages

• It iscritical todevelopa systematicapproachtogatheringanddocumentingpatient information fromwritten and electronicmedical records. Becomingcomfortablewith a consistent data review formatwill assist in efficient datagathering.

chapter summary 61

• Asyoubecomemoreandmorefamiliarwiththekeypharmacy-relatedcompo-nentsofthemedicalhistoryandphysicalexamination,youwillfinditeasiertonavigatethecharttoobtaintheinformationyouneed.

• Besuretofollowanorganizedmethodforidentifyingeachofyourpatient’sproblems.Utilizingthestepstorecognizedrug-relatedproblemswillallowyou to easily identify issues that should be noted on your patient’s prob-lem list, in addition to theirmedical problems and potential preventativemeasures.

revieW QuestiOns

1. What are some challenges that arise when searching for information in themedicalrecord?

2. Whatisthedifferencebetweenclinicalnotesandtreatmentnotes? 3. What are some ways that information can be systematically collected from

a patient’s medical record for the purposes of developing an assessmentandplan?

4. WhatarekeypiecesofinformationthatshouldbegatheredfromtheH&Pinordertoidentifydrug-relatedproblems?

5. What are someways inwhich drug-related problems are utilized to create apharmacist-drivenproblemlist?

references

1. JonesRM.Healthandmedicationhistory. In: JonesRM,RospondRM.Patient assessment in pharmacy practice.2nd ed.Philadelphia;LippincottWilliams&Wilkins;2008;26–38.

2. LeBlondRF,DeGowinRL,BrownDD.Historytakingandthemedicalrecord.In:LeBlondRF,DeGowinRL,BrownDD.DeGowin’s diagnostic examination.9thed.NewYork:McGraw-Hill;2009;15–133.

3. BarkerBN.Securityandprivacyconsiderationsinpharmacyinformatics.In:FoxBI,ThrowerMR,FelkeyBG.Building core competencies in pharmacy informatics.WashingtonDC:AmericanPharmacistsAssociation;2010;423–442.

4. Thrower MR. Computerized provider order entry. In: Fox BI, Thrower MR, Felkey BG. Building core competencies in pharmacy informatics. Washington DC: American PharmacistsAssociation;2010;183–197.

5. NicollCD,PignoneM,LuCM.Diagnostictestingandmedicaldecisionmaking.In:McPheeSJ,Papadakis MA. CURRENT medical diagnosis and treatment 2011. New York: McGraw-HillMedical;2011.Availableat:AccessMedicine.com/CMDT.AccessedJanuary,2013.

6. StrandLM,MorleyPC,CipolleRP,etal.Drug-relatedproblemsandtheirstructureandfunc-tion.DICP, Ann Pharmacother.1990;24:1093–1097.


7. Rovers JP. Identifying drug therapy problems. In:Rovers JP,Currie JD.A practical guide to pharmaceutical care: A clinical skills primer. 3rd ed. Washington DC: American PharmacistsAssociation;2007;23–45.

8. Cipolle RJ, Strand LM, Morley PC. Drug therapy problems. In: Cipolle RJ, Strand LM,MorleyPC.Pharmaceutical care practice: The clinician’s guide.2nded.NewYork:McGraw-Hill;2004;171–198.

9. KaneMP,BricelandLL,HamiltonRA.Solvingdrug-relatedproblems.US Pharm.1995;20:55–74.10. JonesRM.Patientassessmentandthepharmacist’sroleinpatientcare.In:JonesRM,Rospond

RM.Patient assessment in pharmacy practice.2nded.Philadelphia:LippincottWilliams&Wilkins;2008;2–11.

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The Medical Record - Jones & Bartlett Learningsamples.jbpub.com/9781449652722/9781449645106_ch02_037_064.pdf · The medical record can be dissected into five primary components, including