In this four part series, the College will focus on the four domains of the pharmacist practice assessment, highlighting trends that we are seeing in practice. Part 1 focuses on the patient assessment domain.
PATIENT ASSESSMENTS ARE CRITICAL FOR PATIENT HEALTH
For every prescription that is dispensed, pharmacists must ask whether the prescription is therapeutically appropriate. This includes gathering relevant information through dialogue with the patient, and creating, adjusting or reviewing the patient profile. Note that patient profiles need to be maintained; a patient’s health is not static and their profile should be reviewed on a regular basis.
Relevant information can include, but is not limited to:
- Allergies,
- Medical conditions,
- Lifestyle factors (e.g. smoking, nicotine use, cannabis use, caffeine, diet, alcohol, exercise),
- Other prescription medications, over the counter medication and natural health products,
- Changes to patient’s health status, and
- Indication for medication.
Utilizing this information allows for the pharmacist to ensure the appropriateness of the prescription for the patient and identify any drug therapy problems or issues that have the potential to affect the optimization of health outcomes, while also considering patient specific needs.
Every prescription new and refill regardless of how they are packaged must have both the therapeutic check (for appropriateness) and technical check (for accuracy) completed prior to release to the patient.
REFILL PRESCRIPTIONS
In the course of conducting pharmacist practice assessments, College practice advisors have identified that many pharmacists are not conducting appropriate therapeutic checks on refill prescriptions. In many cases, the pharmacist’s perception was that because a patient had a medication before or they haven’t asked to speak with the pharmacist, that there are no problems with the therapy. However, it is ultimately the pharmacist’s responsibility to determine appropriateness before dispensing, without relying on assumptions. A complete therapeutic check process for refill prescriptions is also an opportunity to address medication management and monitoring (see the example patient scenario below).
Some of the activities that a pharmacist may undertake to determine ongoing appropriateness of a medication and/or identify any drug therapy problems or issues that may affect the optimization of health outcomes could include:
- Reviewing the patient profile to identify any issues of adherence or overuse,
- Reviewing the patient profile to identify any drug interactions between the medication being filled and other medications on file,
- Reviewing the patient profile to identify other issues related to the medication being filled (e.g. duplication, contraindications, newer therapy on file, no longer indicated),
- Considering the indication for the refill and the ongoing need,
- Speaking with the patient to determine if any changes have occurred that may not be captured in the patient profile review, and
- Speaking with the patient to gather further information regarding issues identified/flagged through patient profile review.
The best practice for refill prescriptions is to have a process in place to communicate with every refill patient to determine if there are any changes or issues (e.g. effectiveness, adverse effects, new medical conditions/allergies, new medications, medications from other sources). Having a pharmacy staff member ask the patient if they have any questions as a courtesy might be considered good customer service, however it is not a substitute for a patient assessment. Pharmacy staff could, however, assist the pharmacist by asking appropriate questions, such as whether there have been any changes to the patient’s health, and alerting the pharmacist as appropriate.
Additionally, if the dispenser is changing a brand upon a refill (i.e. switching from the original brand to a generic, or from one generic brand to another), it is good practice to address the change with the patient prior to dispensing. This can help prevent any confusion for the patient on why the name of their medication has been changed or appears different (colour, shape, different markings).
AN EXAMPLE PATIENT SCENARIO
The patient is a 59 year old male who has filled his prescriptions at the pharmacy for about 1 year. His patient profile shows that he has Type 2 Diabetes, dyslipidemia, osteoarthritis and is a smoker. He fills his medications mostly on time, doesn’t say much when picking up his medications and you haven’t noticed any changes on his prescriptions profile. He is currently on:
- Atorvastatin 10mg once daily
- Metformin 1000mg twice daily
- Gliclazide MR 30mg daily
- Venlafaxine 150mg once daily
The prescriptions were written six months ago, with a one year supply. There is nothing on file that indicates whether he is on any over the counter medications or natural health products. It is not likely that he will have any kind of follow-up until his refills run out.
AN OPPORTUNITY FOR EVALUATION AND INTERVENTION
Use the Chat, Check, Chart method to identify potential drug therapy problems and evaluate the appropriateness of therapy for this patient:
- I: Is the therapy indicated? Understand the indication and if it is still valid (for example, has anything changed with his health status? Was the medication meant for short term use?)
- E: Is the therapy effective? Understand if the goals of the therapy are being met (for example, are the medications supporting changes in blood sugar?)
- S: Is the therapy safe? Understand if there are changes in medications or conditions, if monitoring is needed (e.g. blood work), if there are potentially other untreated conditions or if additional therapies could be instituted.
- U: Is the patient willing to use/adhere to the therapy? Understand the patient’s compliance with the drug regimen and schedule.
The most effective way of ensuring you have all of the information is to have a quick check in with the patient. It doesn’t need to be long just a basic check on how the medication has been working for them and any changes in their health status or medication use. Try some of the following conversation prompts:
- Can we take a minute to update your patient information since your last visit?
- What has changed regarding your medical conditions since you were last here?
- Are there any new allergies or medical conditions that we should be aware of?
- Are there any new prescription medications you are taking that I should add to your record?
- Are you taking any new non-prescription medications including herbals or vitamins that I should have on your profile?
- What are you taking this medication for?
- How is the medication working for you?
- Are you experiencing any side effects?
- How do you take your medication?
As a result of this evaluation and intervention, you could potentially identify the following for the patient:
- Issues with blood sugar that are not being managed by the current medication. A recommendation could be made to the prescriber to alter dosage or engage in more proactive monitoring. You could also consider adapting the dose.
- An opportunity to discuss smoking cessation. A conversation could be initiated with the patient to explore options for reducing or eliminating his use of tobacco or a note could be made in the file to follow-up with the patient.
- Side effects from one of the medications that could be managed at the pharmacy or could be brought to the attention of the prescriber.
- Or, no immediate issues with the patient are identified, but you are confident that his therapy is therapeutically appropriate.
Ultimately, every time the patient visits the pharmacy it is an opportunity for a check in, counselling and assessment to ensure that their health outcomes are being optimized and that there are no drug therapy problems that could potentially put their health and well-being in jeopardy. As with any other decision made while providing patient care, a notation of the assessment and any action taken or recommendations made as a result should be made on the patient’s profile.
RESOURCES RELATED TO PATIENT ASSESSMENTS
- Chat, Check, Chart The Alberta College of Pharmacists’ resources focused on getting patient information, evaluating the appropriateness of therapy and documentation.
- Optimizing Patient Care Modules Produced by the University of Toronto, these videos help pharmacists practice to their full scope.
- Pharmacist Practice Assessment Criteria Patient Assessment Practice Tool.