PHARMACEUTICAL CARE DOCUMENTATION & COMMUNICATION MATA KULIAH FARMAKOTERAPI I PHARMACEUTICAL CARE DOCUMENTATION & COMMUNICATION Dhanang Prawira Nugraha Departemen Farmasi Klinis STIKes Karya Putra Bangsa Tulungagung dhanang.prawira.nugraha.apt@gmail.com © Dhanang | 2017

REFERENSI WAJIB © Dhanang | 2017

REFERENCES REQUIRED Dipiro, joseph T., Talbert. Robert L., Yee, Gary C., Matzke, Gary R., Wells, Barbara G., Posey, L. Michael., 2011, PHARMACOTHERAPY A PATHOPHISIOLOGIC APPROACH 8TH EDITION, New York, McGraw Hill Alldredge, Brian L., Corelli, Robin L., Ernst Michael E., Guglielmo B. Joseph., Jacobson, Pamala A., Kardjan, Wayne A., Williams, Bradley R., 2013, KODA-KIMBLE & YOUNG’S APPLIED THERAPEUTIC OF CLINICAL USE OF DRUGS. Philadelphia, Lippincot williams & wilkins, Neal, Michael J.,2012., MEDICAL PHARMACOLOGY AT A GLANCE, london, wiley-blackwell Brunton, Laurence L., Chabner, Bruce A., Knollman, Bjorn C., 2012, GOODMAN GILLMAN THE PHARMACOLOGICAL BASIS OF THERAPEUTIC, 12TH EDITION., New York., McGraw Hill. Cipolle, Robert J., Robert J. Cipolle, Peter C. Morley, and Robert J. Cipolle. 2012. PHARMACEUTICAL CARE PRACTICE. New York: McGraw-Hill. Kasper, Dennis L., Hauser, Stephen L., Jameson, J. Larry., Fauci, Anthony S., Longo, Dan L., Loscalzo, Joseph., HARISSON’S PRINCIPLE INTERNAL MEDICINE 19TH EDITION., New York., McGraw Hill Walker., Roger., Whittlesea, Cate., 2012, CLINICAL PHARMACY AND THERAPEUTICS, London, Churchill livingstone. Chisholm-Burns MA, Wells BG, Schwinghammer TL, Malone P, Kolesar J, Rotschafer J, et al. PHARMACOTHERAPY PRINCIPLES & PRACTICE. McGraw-Hill New York; 2010. Sukandar E yulinah, Andrajati R, Sigit JI, Adayana IK, Setiadi antonius A priyatno, Kusnandar. Iso Farmakoterapi. penerbit ISFI; 2008. Widyawati, PRAKTEK FARMASI KLINIK FOKUS PADA PHARMACEUTICAL CARE, Brilian Internasional, 2014 Scwinghammer, Terry L., Koehler, Julia M., 2011, PHARMACOTHERAPY CASEBOOK A PATIENT-FOCUSED APPROACH 8TH EDITION., New York, McGraw Hill Dhillon , Soraya., Raymond, Rebekah., 2009, PHARMACY CASE STUDY, London, Pharmaceutical Press © Dhanang | 2017

OUTLINES © Dhanang | 2017

INTRODUCTION Documentation in clinical pharmacy If you didn’t document it, you didn’t do it,” is a common mantra in many fields of health care. Pharmacists have experience maintaining prescription records, but many lack experience documenting patient care activities. More comprehensive documentation practices are essential when pharmacists implement patient care services, Documentation helps to ensure the delivery of high-quality patient care. Cipolle, Strand, and Morley, pioneers of pharmaceutical care, have written, “If you are not documenting the care you provide in a comprehensive manner, then you do not have a practice.” (Cipolle RJ, Strand LM, Morley PC, 2004) © Dhanang | 2017

INTRODUCTION Communication in clinical pharmacy Communication is the backbone of pharmacy practice and health care. But if you are shy or intimidated by others, then you need to find a way to organize your thoughts and get your message across without getting sidetracked or wasting anyone's time, including your own. © Dhanang | 2017

INTRODUCTION Etiquette for Communicating With Prescribers It is important to carefully word recommendations that are sent to prescribers. Many prescribers recognize the value that pharmacists bring to the patient care team. pharmacists may encounter resistance from prescribers and should strive to carefully word all recommendations so that prescribers do not feel that their judgments are coming under attack or that the pharmacist’s documentation leaves them exposed legally © Dhanang | 2017

INTRODUCTION Communication in health care team Writen Verbal: SOAP (subjektif, objektif, assesment, plan) FARM (finding, Assesment, recomendation, monitoring) PAM (problem, Assesment, monitoring) CORE (condition, outcome, recomendation, evaluation PRIME (pharmaceutical, risk, interaction, mismatch, efficacy) Verbal: SBAR (situation, background, assesment, recomendation) S.O.A.P is one of common communication method between prescribers, nurse anf pharmacist in health care team according profesional competence S.O.A.P is implementation of pharmaceutical care from pharmacist S.O.A.P is one of documentation in clinical pharmacy practice in hospital, clinic or pharmacy © Dhanang | 2017

PHARMACEUTICAL CARE PLAN Assesment Patient database Subjektif Objektif Medical Problem Therapy Care plan Follow up Drug Related Problems monitoring Evaluation Therapy recomendation Counseling © Dhanang | 2017

S.O.A.P PATIENT DATABASE IDENTITY & CHARACTERISTIC SUBJECTIF DATA OBJECTIF DATA MEDICAL PROBLEMS THERAPY FUTHER INFORMATION REQUIRED (FIR) © Dhanang | 2017

S.O.A.P PATIENT DATABASE Arrange patient database can be done with Medical record Patient/family interview © Dhanang | 2017

S.O.A.P IDENTITY & PATIENT CHARACTERISTIC Demographic patient medical history Drug history Allergy Social history Family history © Dhanang | 2017

S.O.A.P SUBJECTIF DATA data form patient, family or other people can’t be confirm indepently that support medical problem Nausea Pain Headache Dizziness faint Drug complient form patient ETC Drug or medical history from patient can’t confirm include in subjectif data © Dhanang | 2017

S.O.A.P OBJECTIF DATA data form obsevation, measuring that other profesion did, that support medical problem & influence drug therapy Vital sign Lab value X-ray CT-scan Clearance cretinine Pharmacokinetic profile Half life Protein bound ETC Drug or medical history from patient can confirm include in objectif data © Dhanang | 2017

S.O.A.P MEDICAL PROBLEMS MEDICAL PROBLEMS Patient complients Abnormality laboratory & examination value Disease or syndrome form clinician Drug related problems the distinction between medical problems and drug-related problems sometimes is unclear, and considerable overlap exists. Likewise, a drug-related problem can cause or aggravate a medical problem. Such drug-related problems could include hypersensitivity reactions; idiosyncratic reactions; toxic reactions secondary to excessive doses; adverse reactions © Dhanang | 2017

S.O.A.P MEDICAL THERAPY THERAPY is the current drug therapy for now the preventive, curative support medical problem The therapy database include Name Dose Posology Frequency Administration (PO;IV;SC;drip; Nebulizer; Topical) © Dhanang | 2017

S.O.A.P FUTHER INFORMATION REQUIRED (FIR) Question to patient or family to get information for analysis drug therapy, monitory and evalution. FIR must support medical problem & influence drug therapy © Dhanang | 2017

S.O.A.P ASSESSMENT After subjectif, objectif & medical problem gathered pharmacist should assess acuity, severity, and importance of these problems. he assessment is usually performed during or immediately after the data gathering while the provider keeps in mind evidence-based practices Assessment must rational & according newest medical guideline or research publication © Dhanang | 2017

S.O.A.P ASSESSMENT Assessment writen as DRP (Drug Related Problems) Terms that used in medical record not rigid but explain the problems In practice should nof follow catergory in clinical pharmacy such as PCNE and ASHP For the academic purpose should use a category in clinical pharmacy © Dhanang | 2017

S.O.A.P ASSESSMENT Don’t use a jugment sentence in DRP writing such as “Wrong”, “not correct” “error” “not adequate” “wrong dose” “wrong administration””wrong route” Dosis glimepride pada pasien tersebut salah Penggunaan antiplatet tidak tepat pada pasien tersebut Seharusnya penggunaan ISDN digunakan subligual use a advice santence to write DRP “recomended” “should” “proper” “advisable” Sebaiknya ISDN digunakan secara sublingual dosis glimepiride tidak adequat masih pada pasien tersebut karena kadar gula darahnya puasa 324 mg/dl Penggunaan antikoagulan lebih baik pada pasien tersebut © Dhanang | 2017

S.O.A.P ASSESSMENT The therapeutic appropriateness of the patient’s drug regimen, including the route and method of administration. Therapeutic duplication in the patient’s drug regimen. The degree of patient compliance with the prescribed drug regimen. Actual and potential drug–drug, drug–food, drug–laboratory test, and drug–disease interactions. Clinical and pharmacokinetic laboratory data pertinent to the drug regimen. Actual and potential drug toxicity and adverse effects. © Dhanang | 2017

S.O.A.P ASSESSMENT Pharmacist make plan based DRP which found in the patient Plan contain Therapy recomendation include dose, posology and duration Therapy monitoring Effectivity Side effect or adverse drug rection Couseling Those three thing not should to do together © Dhanang | 2017

S.O.A.P PLAN Don’t use “command” or “order” such as Dosis paracetamol harus diturunkan menjadi 3 x 500 mg hentikan penggunakan ciprofloxacin karena tidak rasional Monitor kadar kalium darah pasien Harus monitor kadar gula darah pasien Ganti gemfibrozil ke atorvastatin Proper use “advise” sentence Sebaiknya dosis paracetamol diturunkan menjadi 3 x 500 mg Disarakan penggunaan ciprofloxacin dihentikan karena penggunaannya tidak tepat pada pasien bayi karena dapat mengganggu pertumbuhan cartilago pasien Disarankan kadar kalium pasien dimonitor untuk menghindari efek samping hipokalemia Pada kondisi pasien tersebut lebih bijak jika dilakukan monitoring kadar gula darah untuk memonitor efektivitas terapi Bila kontrol trigliserida sulit dicapai maka sebaiknya terapi gemfibrozil diganti dengan atorvastatin © Dhanang | 2017

S.O.A.P CASE Tn X usia 60 tahun 70 kg no RM 02-02-02-05 dirawat di bangsal bedah mulai tanggal 10 februari 2016 dikarenakan mengalami patah tulang paha setelah terjatuh di kamar mandi. Tn X hidup bertiga bersama cucu dan seorang asisten pasien mempunyai riwayat asma sejak kecil dan menggunakan berotec® inhaler selama 3 tahun terakhir pasien mempunyai riwayat alergi paracetamol dan methampyron. Hasil X-ray menunjukkan adanya 3 patahan pada tulang paha kirinya. Setelah menjalani operasi Tn X mengalami demam, menggigil dan nyeri pada bekas operasi dengan skala 6. TTV: TD 130/90 mmHg; RR 24; nadi 90; T 38,70C sedangkan hasil lab pasien WBC 15.200; Hb 12,3%; gula darah acak 120mg/dl; kreatinin serum 0,9mg/dl, Na: 140 mEq/L; K: 4,0 mEq/L; Cl: 110 mEq/L; kolesterol: 180 mf/dl; asam urat: 6,5mg/dl. Selama dirumah sakit pasien mendapakan profenid® suppo 3 x 1 suppo; calc-os® tablet 3 x 1 tablet; primperan® inj 3 x 1; acran® 150mg/5ml inj 3 x 1; zythromax® 250 mg 1 x 1 dan ciprofloxacin 500 mg 2 x 1. luka operasi mengeluarkan nanah dan jahitan tidak menutup secara sempurna © Dhanang | 2017

S.O.A.P CASE CONTOH: Demografi pasien Riwayat penyakit dahulu Tn X 60 thn 70 kg Masuk rumah sakit 10/02/16 Riwayat penyakit dahulu Asma Riwayat pengobatan Berotec inhaler Allergi Paracetamol & methampyron Riwayat sosial Pasien tinggal bersama cucu dan assisten rumah tangga Riwayat keluarga Tidak diketahui © Dhanang | 2017

S.O.A.P CASE CONTOH: Subjektif Pasien nyeri skala 6 © Dhanang | 2017

S.O.A.P CASE Objektif Suhu tubuh 38,70C CONTOH: Objektif Suhu tubuh 38,70C luka operasi mengeluarkan nanah dan jahitan tidak menutup WBC 15.200 Hasil X-ray ada 3 patahan pada tulang paha © Dhanang | 2017

S.O.A.P CASE Problem Medik Infeksi luka operasi CONTOH: © Dhanang | 2017

S.O.A.P CASE Terapi obat Cythromax® 250 mg 1 x 1 CONTOH: Terapi obat Cythromax® 250 mg 1 x 1 Ciprofloxacin 500 mg 2 x 1. © Dhanang | 2017

S.O.A.P CASE CONTOH: Assessment Kondisi pasien memburuk dikarenakan adanya infeksi luka operasi yang belum tertangain dengan baik hal ini ditunjukkan dengan adanya nanah dan luka yang belum menutup dengan sempurna, disertai peningkatan leukosit 15.200 dan suhu tubuh 38,70C © Dhanang | 2017

S.O.A.P CASE CONTOH: DRP Antibiotik belum adekuat untuk mengatasi infeksi luka operasi © Dhanang | 2017

S.O.A.P CASE CONTOH: Plan Disarankan mengganti antibiotik yang sekarang digunakan menjadi injeksi cefazoline karena memiliki penetrasi yang baik sampai ke tulang dengan dosis 0,5 – 1 gram IV 3 kali sehari Monitoring efektivitas: suhu tubuh, WBC, nanah yang ada serta jahitan operasi Monitoring ESO: kreatinin serum, SGPT, SGOT, reaksi alergi Konseling: konseling kepada cucu dan asisten bagaimana cara merawat luka dan menggunakan suppositoria © Dhanang | 2017

S.O.A.P CASE S Pasien nyeri O Suhu tubuh 38,70C luka operasi mengeluarkan nanah dan jahitan tidak menutup WBC 15.200 Hasil X-ray ada 3 patahan pada tulang paha A PM S,O TERAPI ANALISIS DRP Infeksi luka operas S.D.A Zythromax® 250 mg 1 x 1 Ciprofloxacin 500 mg 2 x 1. Terdapat infeksi luka operasi sebaiknya terapi dirubah karena tidak adekuat Terapi tidak adekuat P Disarankan mengganti antibiotik yang sekarang digunakan menjadi injeksi cefazoline karena memiliki penetrasi yang baik sampai ke tulang dengan dosis 0,5 – 1 gram IV 3 kali sehari Monitoring efektivitas: suhu tubuh, WBC, nanah yang ada serta jahitan operasi Monitoring ESO: kreatinin serum, SGPT, SGOT, reaksi alergi Konseling: konseling kepada cucu dan asisten bagaimana cara merawat luka dan menggunakan suppositoria © Dhanang | 2017

S.O.A.P STEP BY STEP Check drug name, compotitions, dose common reason and analysis according disease, patients and drug Spesific reason and Analysis according on guidelines or research publication, protocol Compare with guidelines, research publication, protocol Chose the best recomendation and the reason © Dhanang | 2017

S.B.A.R INTRODUCTION Pharmacist find DRP that needs to be resolved immedietly, so that recomendation delivered verbally or by phone. Verbally recomendation delivered by S.B.A.R format and documented by S.B.A.R format too S.B.A.R is a acronym of S = situation B = backgroun A = Assessment R = recomendation © Dhanang | 2017

S.B.A.R INTRODUCTION Before we deliver recomendation orally using S.B.A.R format we say greetings and mention our identity to the doctor We mentioning situation, background, assesment and recomendation in sequence and to say thanks After we delivered orally, it documented in medical record, registration should be accompanied by date, date and initial from the doctor and pharmacist © Dhanang | 2017

S.B.A.R SITUATION S = Situation What happen with patients? patient name Patien room/medical record number Vital sign or laboratory value that changing or patien condition “pasien Tn X mendapatkan metoprolol dan atenolol dari dokter yang berbeda” “pasien Ny Y kamar 2A mengalami bengkak pada kedua matanya” “pasien Tn Z nomer RM 01-01-00-01 mengalami penurunan tekanan darah, sekarang tekanan darahnya 80/40 mmHg” © Dhanang | 2017

S.B.A.R BACKGROUND B = background What is clinical background or context? Patient condion Drug name Drug dose Drug use Drug administration “atenolol tablet 50 mg 1 x sehari diresepkan oleh dokter A dan metoprolol tablet 100 mg 2 x sehari diresepkan oleh dokter B, Sp.JP diindikasikan untuk hipertensi ” “pasien mengalami stroke dan mendapatkan terapi ketorilac injeksi 30 mg 2 kali sehari untuk mengatasi nyeri kepala yang berat” “Tn Z mengalai gagal jantung stage 4 dan telah mengalami dekompensasi, serta adanya cardiomegali pada hasil rongten” © Dhanang | 2017

S.B.A.R ASSESSMENT A = assessment What i think a problem is? Analysis problem from the guidelines, research publication, drug spesialite, ETC “karena metoprolol dan atenolol keduanya beta blocker yang bekerja secara selektif pada reseptor beta 1 sehingga akan berbahaya karena akan menurunkan nadi dan tekanan darah pasien” “kelopak mata yang bengkak pada Ny Y merupakan akibat dari reaksi hipersensitivitas terhadap NSAID dalam hal ini adalah reaksi hipersensitif terhadap ketorolac” “tekanan darah yang terus turun pada pasien gagal jantung dapat berakibat fatal sehingga perlu ditingkatkan dengan menggunakan obat-obatan” © Dhanang | 2017

S.B.A.R RECOMENDATION R = recomendation What would i recomend? Recomendation if approved by doctor or if not apporved by docter it still documented and include tha doctors disagree Drug name Drug dose Drug administration “gunakan salah satu untuk menghindari reaksi obat yang tidak diinginkan” “hentikan penggunaan ketorolac dan ganti dengan menggunakan tramadol injeksi 3 x 1 ampul dan tablet amitriptilin 3 x 1 tablet” “gunakan drip dopamin 300mcg/menit , dobutamin 180mcg/menit dan norepinephrine 4 mcg/menit © Dhanang | 2017

S.B.A.R STEP BY STEP Do your research ahead of time and organize your thoughts. Figure out what you need to say using the 4 components of SBAR. If you're calling a physician, write down on a piece of paper what you're calling about. Take out the fluff, but make sure to include relevant, important information. Have the paper ready when you make the call. If you feel nervous or get someone who is argumentative, you can always lean back on the sheet for guidance. Sometimes, you can cover the background and assessment together, because they are more than likely related. Listen closely in case the person on the other end of the conversation offers a point you hadn't thought about. © Dhanang | 2017

LATIHAN BUATLAH DATABASE PASIEN Ny y datang dengan keluhan nyeri terutama pada malam hari nyeri akan hilang dengan makan terkadang hal tersebut tidak membantu, pekerjaan ny X adalah seorang direktur perusahaan ekspor impor dan mengkonsumsi kopi atau teh 5 gelas perhari. Pasien merasakan mual, kembung dan sendawa tanpa disertai dengan muntah. Riwayat keluarga ayah penyakit jantung koroner dan stroke ,ibu diabetes dan kanker payudara, kakak kandungnya mempunyai riwayat hipertensi hiperkolesterolema. tinggi badan 145 cm, berat badan 70 kg, TD 110/90 mmHg, nadi 90, RR 16 kali permenit, suhu tubun 37,5oC. Na 142 mEq/L, K 4.7 mEq/L, Cl 98 mEq/L, Hb 10.1 g/dL, Hct 30%, Plt 320 × 103/mm3, Albumin 5.0 g/dL Selama perawatan pasien mendapatkan obat ondansentron inj 3 x 4 mg, antasida tab 3 x 1 tab, metoclopramide inj 3 x 2 ampul, ranitidine 3 x 2 ampul, sucralfat syr 3 x 10 ml © Dhanang | 2017

LATIHAN BUATLAH DATABASE PASIEN Tn A usia 34 tahun masuk RS dengan keluhan nyeri perut bagian ulu hati, mual dan disertai dengan muntah, warna muntah berwarna kehitam-hitaman, pasien memiliki riwayat rheumatoid arthritis 10 tahun. skala nyeri pasien 8. hasil endoskopi pasien terdapat beberapa ulkus pada bagian lambung. pasien merokok 1 pak per hari. hasil pemeriksaan laboratorium IgG anti H.pylori (-), TTV: TD 120/80 mmHg; RR 24; nadi 90; T 38,70C sedangkan hasil lab pasien WBC 9.200; Hb 12,3%; gula darah acak 120mg/dl; kreatinin serum 0,9mg/dl, Na: 89 mEq/L; K: 4,0 mEq/L; Cl: 75 mEq/L, Hb 13,0 g/dl. pasien rutin mengkonsumsi obat voltaren® 3 x 2 tab, lameson® 8 mg 3 x 1 tab, imuran® 1 x ½ tab. Diagosa dokter: ULKUS PEPTIK. Dokter meresepkan: nucral® 3 x 10 ml, Caprazol® 2 x 1 tab, acran® inj 3 x 2 ampul, mucosta® 3 x 1 tab, paracetamol tab 3 x 1 tab jika nyeri, infus NaCl 20 Tetes per menit Pasien obesitas, belum ada obat mual © Dhanang | 2017

LATIHAN BUATLAH DATABASE PASIEN Anak A no RM 57-67-00-00 usia 13 tahun berat badan 33 kg, pasien memiliki riwayat asma sejak bayi, pasien memiliki riwayat alergi debu dan alergi bulu, menggunakan ventolin nebulizer atau ventolin inhaler jika terjadi serangan asma. Pasien masuk ke RS dengan keluhan sesak nafas suhu 37,4o C. TD 100/70 mmHg, RR 40 kali permenit, nadi 120 kali per menit. Pasien mendapatkan combivent® nebulizer 2 x 1 vial, aminophyline inj 4,6 mg/kgBB, budesonide® turbuheler 3 x 100 unit dan acetilsystein 3 x 1 tab serta infus RL 10 tetes per menit © Dhanang | 2017

S.O.A.P CASE S Pasien sesak nafas O Suhu tubuh 37,40C TD 100/70 mmHg, RR 40 kali permenit Nadi 120 kali per menit A PM S,O TERAPI ANALISIS DRP Asma S.D.A combivent® nebulizer 2 x 1 vial aminophyline inj 4,6 mg/kgBB budesonide®turbuheler 3 x 100 unit acetilsystein 3 x 1 tab infus RL 10 tetes per menit Terapi tidak adekuat P Disarankan mengganti antibiotik yang sekarang digunakan menjadi injeksi cefazoline karena memiliki penetrasi yang baik sampai ke tulang dengan dosis 0,5 – 1 gram IV 3 kali sehari Monitoring efektivitas: suhu tubuh, WBC, nanah yang ada serta jahitan operasi Monitoring ESO: kreatinin serum, SGPT, SGOT, reaksi alergi Konseling: konseling kepada cucu dan asisten bagaimana cara merawat luka dan menggunakan suppositoria S.O.A.P CASE © Dhanang | 2017

S.O.A.P CASE CONTOH: Demografi pasien Riwayat penyakit dahulu An. A 13 thn 33 kg RM 57-67-00-00 Riwayat penyakit dahulu Asma Riwayat pengobatan ventolin nebulizer atau ventolin inhaler Allergi Alergi debu dan alergi bulu Riwayat sosial Tidak diketahui Riwayat keluarga © Dhanang | 2017

S.O.A.P CASE Subjektif Pasien mengeluh sesak nafas © Dhanang | 2017

S.O.A.P CASE Objektif Suhu tubuh 37,40C TD 100/70 mmHg, RR 40 kali permenit Nadi 120 kali per menit © Dhanang | 2017

S.O.A.P CASE Problem Medik Asma © Dhanang | 2017

S.O.A.P CASE Terapi obat CONTOH: combivent® nebulizer 2 x 1 vial aminophyline inj 4,6 mg/kgBB budesonide®turbuheler 3 x 100 unit acetilsystein 3 x 1 tab infus RL 10 tetes per menit © Dhanang | 2017

S.O.A.P CASE CONTOH: Assessment © Dhanang | 2017

S.O.A.P CASE CONTOH: DRP Antibiotik belum adekuat untuk mengatasi infeksi luka operasi © Dhanang | 2017

S.O.A.P CASE Plan Disarankan CONTOH: Plan Disarankan Monitoring efektivitas: suhu tubuh, WBC, nanah yang ada serta jahitan operasi Monitoring ESO: kreatinin serum, SGPT, SGOT, reaksi alergi Konseling: konseling kepada cucu dan asisten bagaimana cara merawat luka dan menggunakan suppositoria © Dhanang | 2017

© Dhanang | 2017