Presentation on medication history interview and soap notes

pharmacy practice is vital activity performed by pharmadians along with physicians to enhance the quality and span of life of patient .mediaction history interview is is an essential to know and presentation of case collected in universally accepted format .

1. PRESENTATION ON MEDICATION HISTORY INTERVIEW AND PRESENTATION OF A CASE PRESENTED BY : U.SUCHITRA PHARM D IV YEAR P.RAMIREDDY MEMORIAL COLLEGE OF PHARMACY

2. To review current medical treatment and to identify suitable additional treatments ,medical professionals require complete and reliable medication history Medication history can be defined as A Medication history is a detailed, accurate & complete account of all prescribed & non-prescribed medication that a patient had taken or is currently taking prior to a initially institutionalized or ambulatory care. Importance of medication history interview 1)Preventing prescription errors & consequent risk to patient 2)It should encompass all currently & recently prescribed drugs, previous adverse drug reactions including herbal or alternative medicine & adherence to therapy for better care plan.

3. Steps to be involved in medication history collection Patient selection : Establish the identity of the patients who are likely to benefit from interview Self preparation : Understand the patients medical condition & therapy before commencing the interview. Introduction : Introduce your self & explain the purpose of the interview Conduct interview : Obtain all relevant information using a combination of open ended & close ended questions.

4. a well designed and structured approach helps to collect Relevant and complete information . The following information is commonly collected Currently and recently prescribed medicines Medicines purchased without prescription (OTC drugs) Vaccination status especially in children or some times in adults also e.g : hepatitis vaccine ,malarial vaccine covid vaccine etc Alternative or traditional remedies e.g . ayuveda,siddha , hakim medicine etc Description of reactions and allergies to medicine or food Medicines found to be ineffective Adherence to past treatment courses and use f adherence aids.

5. QUESTIONS ASKED TO OBTAIN INFORMATION Which community pharmacy do you use? Any allergies to medications and what was the Reaction Which medications are you currently taking: The name of the medication The dosage form The amount(specifically the dose) How are you taking it(by which the dose and by which route How many times a day What vitamins or other supplement are you talking? Have you recently started any new medicines? Did a doctor change the dose or stop any of your medications recently ?

6. Did you change the dose or stopped any of your medications recently? Are you change the dose or stopped any medications because of unwanted effects? Do you sometimes stop taking your medicine whenever you feel better? Do you stop taking your medicine if it makes you feel worse? the obtained information is documented and the information is compared with the medicines given and information obtained from other sources like medical notes or practitioners file . the interview is conducted based on patient condition. some embarrasing questions to patient are avoided .body postures or non verbal communication plays a significant role in interview. confidentiality is maintained in patient information

7. Patient medication history interview help the pharmacist to establish rapport with the patient, commence preliminary counselling & help to formulate on ongoing pharmaceutical plan.

8. PRESENTATION OF CASE Patient information is documented and presented in legal format. this activity is to input into the patient medical records . this allow the providers to share information in universal, systematic and easy to read format. In previous days FARM note(findings ,assessment ,resolution ,management and follow up) is followed .but now SOAP note is followed because is an universal format and easy to understand and interprete the data.

9. SOAP note S- subjective evaluation O- objective evaluation similar to findings in FARM note A- assessment similar to A in FARM note P- planning similar to monitoring and follow up in FARM note. 1.S- subjective evaluation: A patient specific subjective information as it gives a basis for or leads to recognition of pharmacotherapy problem or indication for pharmacist intervention. Subjective information includes chief complaints (c/o) and duration and severity of symptoms. It also includes past medical history , medication history surgical history, family history . sometimes the data to be noted or not clearly delineated as subjective or objective data there may be preponderence of one type of data in that case both combined and noted as S/O findings.

10. O- objective findings: It includes various abnormalities mesured.physical appearence e.g.cyanosis , icterus etc height ,weight Vitals information e.g. Pulse, bp,temprerature etc Systemic examinations eg,CVS,CNS,RS etc Laboratory data Eg.haematological data ,urinary data ,thyroid tests ete malarial test,dengue tests etc Radiological information eg. CT scans ,MRI , X-ray, USG of abdomen etc Other investigations like ECG,EEG etc

11. A- Assessment : Diagnosis is not performed by the pharmacist it is under Physician .instead the assessment section is includes Pharmacist evaluation of subjective and objective findings. in assessment the patient indication ,severity ,urgency and Priority of problem . The short term and long term goals of intervention are proposed or provided examples of short term goals : i.Eliminate symptoms ii.Lower bp to 140/90 with in 6 weeks iii.Manage acute asthma iv.Asthma flare up without requiring hospitalisation.

12. P- planning : In medical notes the planning section includes diagnostic Test, physician intended drug regimen,surgical procedure . But the pharmacist does not have authority to recommend diagnostic tests. It includes drugs names (brand or generic), dosage form , route of intake of medicine. Dose Frequency of intake some notations if any drug or food is avoided during the treatment with particular drug. Diet plan to some patients planning also includes monitoring and follow up of patient condition and drug efficacy

13. Based on state of progression ( can be notes through clinical lab findings and symptoms) changes to be made in therapy .either reduction in dose ,increase in dose, Change of drug etc drug efficacy , toxicity and adverse events are monitored. A case is given below to present in SOAP format.

14. SOAP ANALYSIS INCLUDES pharmacist work up of drug therpy Desired outcomes Therapeutic end points Medication related problems Pharmacist interventions Monitoring plans Patient education

15. A case is given below to present in SOAP format. Mr. Sp is a 52 year old business man who recently consulted His physician for burning pain in his feet., known diabetic for 4 years for which he has been following diabetic following a diabetic diet . his social history reveals that he is tobacco smoker and drinks alcohol accasionally .O/E his bp was 160/95 mm of hg . his doctor ordered a range of laboratory tests includes FBS,PPBS , BUN and serum creatinine His FBS was found to be 8.42mmol/lit (normal3.9 to 6.1 mmol /lit)PPBS 10.28 mmol /lit(normal8.4mmol/lit), BUN6.06 mmol /lit(normal 2.9 to 7.1 mmol /lit)and serum creatinine 52mmol/lit(normal 62 to 133mmol/lit)Mr. Sp was given op prescription for following Medication Rx cap.gabapentin 300mg one TID tab.Ramipril 2.5mg one OD tab.gliclazide SR 30mg one OD tab.metformin 500mg one BD

16. Thank you