Dipiro's Pharmacotherapy A Pathophysiologic Approach 12TH EDITION 2023 ALGRAWANY
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EDITORS:
by Joseph T. DiPiro, Gary C. Yee, Stuart T. Haines, Thomas D. Nolin, Vicki Ellingrod, L. Michael Posey
Pages: 6475
- Language: English
- Format: PDF
- Size : 146 MB
KEY CONCEPTS
. A professional patient care practice is built on three essential elements: a philosophy of practice, a pati nt care process, and a practice management system .
. A professional patient care practice is predicated on a patientpractitioner relationship established through respect, trust, and effective communication. Patients, and when appropriate, caregivers and family, are actively engaged in decision . making
. . Adopting a uniform patient care process—a consistently implemented set of methods and procedures—serves as a framework for each patient encounter, increases quality and accountability, and creates shared language and expectations.
. The patient care process includes five essential steps: collecting subjective and objective information about the patient; assessing the collected data to identify problems and set priorities; creating an individualized care plan that is evidencebased and costeffective; implementing the care plan; and monitoring the patient over time during followup encounters to evaluate the effectiveness of the plan and modify it as needed.
. The patient care process is supported by three interrelated elements: communication, collaboration, and documentation. Interprofessional teamwork and information technology facilitate the effective and efficient delivery of care.
. A practice management system includes the infrastructure to deliver care. This includes physical space, documentation systems, payment for services, and qualified support personnel.
INTRODUCTION
The patient care process is a fundamental series of actions that guide the activities of health professionals. All health professionals who provide direct patient care should use a systematically and consistently applied process of care in their practice.1 Until recently, the language to describe the process for delivering comprehensive medication management services was illdefined. In 2014, the Joint Commission for Pharmacy Practitioners (JCPP)—representing 11 national pharmacy organizations—endorsed a framework for providing clinically oriented patient care services called the Pharmacist’s
Patient Care Process.2 However, the framework and the language to describe the process are not unique to the pharmacy profession. Indeed, medicine, nursing, and dentistry all follow a putatively similar process of care3 (see Table 11). For example, the American Nursing Association (ANA) outlines the nursing process with steps that include assessment, diagnosis, outcomes/planning, implementation, and evaluation.4 The Academy of Nutrition and Dietetics collapses these general steps into four steps, outlining the nutrition care process to include nutrition assessment, diagnosis, intervention, and monitoring/evaluation.5 Although the care process is similar across disciplines, each health profession brings a unique set of knowledge, skills, attitudes, and values to the patient encounter.
Health professionals who provide direct patient care are often called practitioners. To practice is what health professionals do to bring their unique knowledge and skills to patients. A practice is not a physical location or simply a list of activities. Rather, a professional practice requires three essential elements: (1) a philosophy of practice, (2) a process of care, and (3) a practice management system.3 These three interrelated concepts make the delivery of patientcentered care possible. Health professionals have an ethical obligation to promote the health and wellbeing of the patients they serve. Thus, a philosophy—the moral purpose and a commonly held set of values that guides the profession—is the critical foundation on which the practices of pharmacy, medicine, nursing, and dentistry are built.11 A philosophy of practice is often formally articulated in the professional code of ethics endorsed by professional organizations and an oath that is recited by members of the profession during rituals and ceremonies. In addition to a code of ethics, most professions have an informal set of beliefs and values that inform selfproclaimed and societal expectations. For example, the concept of pharmaceutical care is not formally included in the code of ethics for the profession of pharmacy or the oath of a pharmacist.12,13 However, informally, pharmacists understand they have a unique responsibility for addressing the drugrelated needs of patients and should be held accountable for preventing,
identifying, and resolving drug therapy problems.14 Similarly, dentistry, nursing, and medicine have both formal and informal expectations that guide their professional practice. A process of care that is systematically and consistently applied during each patient encounter increases the likelihood that optimal health outcomes are achieved.15 The patient care process used throughout this book includes five essential steps: (1) collecting subjective and objective information about the patient; (2) assessing the collected data to identify problems, determine the adequacy of current treatments, and set priorities; (3) creating an individualized care plan that is evidencebased and costeffective; (4) implementing the care plan; and (5) monitoring the patient over time during followup encounters to evaluate the effectiveness of the plan and modify it as needed (see Fig. 11). In addition to the five fundamental steps, a patientcentered approach to decisionmaking is essential.16 To be patientcentered requires effective communication and seeking to understand the patient’s needs, preferences, and values. It also requires interprofessional collaboration—working with other health professionals to develop and implement a shared plan of care.17 Each step of the process must be documented. These steps are interdependent, and completing all five steps is necessary to achieve the greatest impact. While the process of care is common to all, each profession has a unique body of knowledge and skills they bring to bear when assessing the data and formulating plans.
IMPORTANCE OF A CONSISTENT PROCESS OF CARE
The stimulus for developing the patient care process for pharmacy was the wide variation observed as pharmacists provided direct patient care, often using the same terminology to describe diverse services or, conversely, the same service is described using different terminology. As patient care services provided by pharmacists, physicians, nurses, and any healthcare practitioner cannot operate in a silo, the services must be clearly articulated and well understood by patients, their caregivers, payers, and other care team members. Without a consistent patient care process, it has been challenging for the pharmacy profession to communicate the pharmacist’s role to groups external to the profession and establish the distinct value pharmacists bring to an interprofessional care team. Moreover, the patient must know and understand what is to be delivered and to determine how best to receive the care provided. Likewise, other healthcare team members must determine how best to integrate the pharmacist’s work into their efforts caring for the patient. Structure is essential to maintaining consistency. Systematically implementing a framework for care that is consistently applied assures no important step is overlooked and actions that may lead to greater harm than benefit are reduced or eliminated. Defining a standardized process of care enables data collection for quality assurance and research purposes to demonstrate the value of a service. In the hospital setting, care pathways and standard order sets are examples of standardized care processes that have been used for many years. Creating a standardized patient care process is not intended to reinvent “the wheel” but to create a common framework and language. The process of care described throughout this text provides an easily understood approach that is universally recognized.
PATIENT CARE PROCESS TO OPTIMIZE PHARMACOTHERAPY
There are two aspects that typically differentiate a professionspecific process of care. First, the application of the care process is defined within the context of the profession’s knowledge and expertise. For pharmacy, the patient care process is focused on a patient’s medicationrelated needs and their experience with medication therapy.3 Dentists and dental hygienists employ a patient care process focused on a patient’s oral health needs.21 The nursing care process is applied to provide a holistic approach to a patient’s health needs and include physical and mental health, sociocultural issues, spirituality, as well as economic and lifestyle factors.4 The general approach to providing care to an individual patient in each of these disciplines is similar; however, the focus of the process is distinct.
The second way in which each profession uniquely addresses a patient’s needs is the manner in which patientspecific information is assessed. When assessing information collected from a patient (eg, history of present illness, physical examination, laboratory data), physicians employ a clinical reasoning process called “differential diagnosis” to weigh the probability of one disease versus other diseases that possibly account for the patient’s signs and symptoms. In the case of dental hygienists, the American Dental Hygienists Association notes that an assessment includes not only a health history and clinical assessment but also a “risk assessment” that includes 11 areas of evaluation.5 For pharmacists providing comprehensive medication management, the assessment step involves a systematic examination of the indication, effectiveness, safety, and adherence for each of the patient’s medications. This is a unique way of approaching a patient’s health needs. No other discipline applies a systematic assessment process to a patient’s medications and their medication experience in this manner.
Several publications and resources have outlined elements of the patient care process to deliver comprehensive medication management services.2,11,17,22,23 There is relative consistency between these sources regarding the core elements. What varies is the specificity of the operational definition of each of the process components. Detailed operational definitions help to establish consistency across all practitioners applying the patient care process.23 This care process is not specific to a care setting—the process can be applied in any setting when providing comprehensive medication management. What often varies is the information collected and its source, as well as the duration of time to complete the process. For example, in an ambulatory care clinic, the patient is often the most important source of information, but in a critical care unit of a hospital, there is a greater reliance on laboratory tests and special diagnostic studies. Similarly, the process of care unfolds in hours or days in acute care settings but may extend over weeks or months in chronic care environments.
Collect Information
When initiating the patient care cycle, a practitioner assures the collection of the necessary subjective and objective information about the patient and is responsible for analyzing the data to understand the patient’s relevant medical needs, medicationrelated problems, and clinical status. In some cases, this information is directly collected by interviewing the patient or reviewing a medical record. In other cases, the practitioner may rely on other personnel to collect the information to be used in the assessment. This may include a blood pressure determined by a clinical assistant or a list of active medications recorded by a nurse. However, it is ultimately the practitioner’s responsibility to assure that all necessary information is collected and that the data is accurate, regardless of the source. This information is critical to the ability of the practitioner to complete an assessment that will appropriately address all of a patient’s medicationrelated needs (see Table 12).
