Patient Assessment and Clinical Interviewing

Common Communication Mistakes Health Care Practitioners Make

From: “Lessons from medicine and nursing for pharmacist-patient communication”, Am Jour of Health System

Pharmacists, Vol. 53, June 1996, pages 1306-14.

Common Mistakes:1. Failure to greet patients, tell them who you are and

the purpose of your interaction with them.2. Failure to find out what is bothering the patient –

worries, concerns, issues – how the patient feels about their condition.

3. Accepting vague information too easily and not probing to find out more specifics.

4. Failure to verify that what you thought you heard, was what the patient really meant…

5. Failure to encourage patient questions.6. Failure to be responsive to patient questions.

Common Mistakes:7. Not paying attention to the verbal and NON-verbal

communication messages sent by patients.

8. Avoiding information that is personal.

9. Using too many closed ended questions.

10. Allowing interruptions.

11. Drawing conclusions too soon.

12. Failure to provide appropriate information in the form of counseling.

13. Not understanding the patients viewpoint.

14. Poor reassurance.

Cultural Issues

“Home Remedies?”

Sample questions to explore cultural beliefs about health,

illness and treatment:• What do you think caused your problem?• When /why do you think it started when it did?• How bad is your sickness?• What do you think should be done to get rid of

this sickness?• How have you treated this illness?• What worries you about this sickness?• Do you think your treatment will help?

Recommendations to Enhance Cultural Sensitivity

• First, all your communication skills from the tool box still apply.

• Recognize that cultural diversity exists.• Accept that new to you can be stressful to

you.• Know your own culturally derived

preferences and values.• Rely on your rapport!

Recommendations to Enhance Cultural Sensitivity

• Listen and attend to verbal and non-verbal cues that could provide information to you.

• Remember that YOU might be facing something completely new to your belief system.

• Develop a genuine acceptance, respect and tolerance for your patient’s cultural values.

Recommendations to Enhance Cultural Sensitivity

• Acknowledge that you don’t know everything and ask your patients to explain the things you don’t understand.

• Stephen Covey: “seek first to understand”.• Do not label or judge customs, norms, or habits

your patients present.• Approach cross cultural situations with a

willingness to explore your patient’s world.• Meet and develop rapport with members of other

cultures.!

When will I need patient assessment or clinical interviewing skills?

The Pharmacy Care Process

Collect and use patient information

Identify patients’ drug related problems

Develop solutions to these problems

Select and recommend therapies

Follow up to assess patient outcomes

When will I need patient assessment or clinical interviewing skills?

• Patient counseling• Examining patients• Making OTC recommendations• Many other situations:

– hospitals, long term care

– Ambulatory clinics such as anticoagulation, other disease management efforts, HTN, diabetes, asthma, flu shot clinics, collaborative practices with physicians and other providers

We want to differentiate assessment and interviewing

from counseling – but the same skills apply.

One of the primary differences is documentation.

Questions asked in the background of the pharmacists mind while conducting patient

assessment activities:

Patient Assessment Questions:

• Are any of the patient’s complaints or abnormal objective/physical findings related to drug therapy?

• What are some other possible causes of the patient’s complaints / symptoms?

• Are each of this patient’s medications appropriately prescribed?

Patient Assessment Questions:

• Is each medication the best one for this patient to be taking? Safest, most effective?

• Is this the right dose given the patient specific information (severity, size, gender, etc.)

• Is the patient having any apparent drug related side effects?

Patient Assessment Questions:

• Are any possible drug interactions present?

• Is this patient able to follow this drug regimen?– Does the patient know how to use this

medication correctly?

• Is additional medication needed to resolve the patient’s complaint / symptom?

Documentation

• Provides a permanent record of patient information.

• Provides a record and evidence of pharmacy care provided.

• Communicates to other practitioners what you have done.

• Provides a legal record of what you have done.• Provides documentation for billing purposes.

Documentation

• Legally, “…if it isn’t documented it wasn’t done…”

• From a billing perspective, each CPT Evaluation and Management Code requires certain information be recorded in the chart.

• 99211; very basic, 5 minutes or less. Requires only 1 vital, date, provider, problem addressed.

Pharmacy Consultant Note Athens Primary Care Pharmacy Clinic

Patient Name: Sample Patient Consult Date: 10/03

Medication (Name/Strength/Dose/Route/Frequency)

Indication Medication (Name/Strength/Dose/Route/Frequency)

Indication

Nexium 40mg—1 PO QD GERD Tramadol 50mg—3 PO QAM Pain

Amaryl 2mg—1 PO QD Type 2 diabetes Promethazine 25mg—PRN Nausea

Diphenoxyalate/Atropine—PRN Diarrhea Ketoprofen 20% in Lipoderm Gel—topical Knee stiffness

Tricor 160mg—1 PO QHS Cholesterol HCTZ 12.5mg—1 PO QAM HTN

Altace 10mg—1 PO BID HTN

Potential Problem Recommendation Recommendation For MD Accepted Y/N (if no,

explain) Blood pressure fluctuates greatly from day to day Add another BP med, possibly a CCB after complete evaluation

Y / N

Diabetes not well controlled Need to check A1Cs; pt. needs to check blood sugar, record it for monitoring; add 2nd drug if appropriate

Y / N

Amaryl has no refills Refill if appropriate Y / N

Is cholesterol being controlled? Check lipids Y / N

Pharmacy Student: J.C. Faculty Advisor: Dr. Matt Perri, Dr. Jennifer Phillips

The SOAP Note

• Subjective – complaints, symptoms, recent history, past medical history, medication history, allergies, social and family history, review of systems.

• Objective – vital signs, physical findings from examination, labs tests, blood levels of drugs, medication profile.

• Assessment – critical thinking and analysis of the problem.

• Plan – actions to be taken.

Problem Oriented Note

• Generate a list of patient problems and provide a SOAP note for each problem (or closely related problems.)

• Be consistent.

• When no drug therapy problems are noted, state this.

General Types of Data to Collect in a Clinical Interview

• Name, address, phone, fax, email, etc.• Height and weight (physical assessment).• Primary physician, specialists, dentists, addresses

and phones if possible.• Insurance information (copy of card if possible).• Rx and OTC medication lists.• Herbal supplements, vitamins, and any other

substances used.

General Types of Data to Collect in a Clinical Interview

• Medical problem list, including date diagnosed, surgeries, hospitalizations, etc.

• Pregnancy, lactation.

• Alcohol and tobacco use.

• Labs, if available.

• Special monitoring that the patient performs.

General Types of Data to Collect in a Clinical Interview

• Possible compliance barriers.

• Any patient concerns or questions

• Name and title of person collecting the information.

Specific Data Needed:

• Chief Complaint– A brief statement of why the patient is seeking

care.– 1-2 primary symptoms with their duration.– Recorded in the patient’s own words.– Remember, patient’s may not always have a

CC: they may present with a problem they do not know is drug related.

Specific Data Needed:

• History of present illness– Timing, onset, duration and frequency of Sx.

– Location

– Quality (sharp, dull, ache, red blood, tarry stools)

– Quantity or severity of Sx (mild, moderate, severe)

– Setting: when do the Sx occur?

– Aggravating or relieving factors

– Associated symptoms (other Sx that occur in conjunction with the primary Sx)

Specific Data Needed:

• Past Medical History– List of past problems, related or not to the CC

• Family History– Presence or absence of illness in the immediate

family (living or dead, illnesses– F 67 (CVA)

• Social History– ETOH, tobacco, exercise, etc.

Specific Data Needed:

• Review of Systems– General health– Skin, hair and nails– Eyes, ears, nose and throat– Head and neck– Respiratory system– Cardiovascular– Gastrointestinal

Specific Data Needed:

• Review of Systems– Hepatic / Renal– Musculoskeletal– Nervous system– Mental status– Endocrine system (diabetes and thyroid)– Male reproductive system– Female reproductive system