handbook hhc draft

2

(Patient centered care)

() 13 () (Drug related problems)

. ,

(), . . .

. 1 .. 2554

3

. .., Centro Escolar University, .. (M.B.A) ()

.

..

.

..

.

.. (Pharm. D)

.

.. (Pharm. D)

4

5 7 8 (Medication Therapy Management: MTM) 9 11 13 14 15 17 18 20 29 30 39 43 45 49 1 51 51 1 : 54 2 : 58 3 : 72 4 : 79 5 : 82 2 87 88 3 89 90 4 96 (Patient profile) 97

5

1 ( )

1

1

1.

1.1 (Quality) 1.2 (Access)

1.3 (Cost) 1.4 (Efficacy)

1 . . :

, 2549.

6

2. 2.1 2.2

3. (Health Service Strategy) 4 3.1 (Health Promotion)

3.2 (Disease, Conditions Prevention)

3.3 (Curative) 3.4 (Rehabilitation)

(Health Care team)

(Drug related problems)2,3

, ,

, 2

(Non-compliance)

2 Hepler CD., Stand LM.,. Opportunities and responsibilities in pharmaceutical care. Vol. 47, in Am J Hosp Pharm., 533-543. 1990. 3 Strand LM.,et al. "Q and A from the pharmaceutical care project in Minnesota." Am Pharm, no. MS35 (1995): 30-39.

7

1.

2. 3. / /

4.

(Pharmaceutical care)4

1. (Pharmaceutical care for individual patients) 1.1 (Institutional pharmaceutical care) 1.2 (Home pharmaceutical care)

2. (Pharmaceutical care for the community) 2.1 (Self care) 2.2 (Self medication) 2.3 (Health promotion)

4

(Promote patient safety), (Improve quality of care),

(Cost effective care) (Increase patient satisfaction)

4 John P.R., et al. A Practical Guide to Pharmaceutical care: A clinical skills Primer. Vol. 3, in Am Pharm., 1-139. 2007.

8

(Medication therapy

management: MTM)

(Home Health Care)5

(Continuing Care)

( )

(Holistic Care)

(Patient Family Participation)

(Health Promotion) (Self care)

(Community Pharmacist Home Health Care)6

(Medication therapy Management: MTM)

(Pharmaceutical Care in Home Health Care)

(Medication Therapy Management: MTM)7

5 Robert L.M. Introduction to Health Care Delivery: A Primer for Pharmacists. Maryland: Aspen Publishers Inc., 1998. 6 Robert L."Home Care Pharmacists." Introduction to Health Care Delivery: A Primer for Pharmacists, 160 164. Aspen Publishers Inc, 1998. 7 Melissa S.M. "Medication Therapy Management: Its Relationship to Patient Counselling, Diease Management and Pharmaceutical Care." J

Am Pharm Assoc. 5, no. 47 (2007): 620-628.

9

(Medication Therapy Management: MTM Model)8

MTM . . 2004

American Pharmacists Association (APhA) National Association of

Chain Drug Store (NAADS) Foundation

,

,

(Pharmaceutical

Care) MTM

MTM

1. (Medication therapy review) 2. (A medication action plan) 3. (Intervention and referral) 4. (Documentation and follow-up) 5. (A person medical record)

1. (Medication therapy review: MTR) 1.1 ,

- - (Understanding), - (Expectations), (Concern) - (Behavior)

1.2 (Monitoring)

1.3 (Medication Related Problems) 1.4

- (Indications) - (Efficacy) - (Safety) - (Compliance)

1.5 , (Adherence)

1.6

8 American Pharmacists Association and National Association of chain drug Foundation. "Medication Therapy Management in Pharmacy

Practice: Core Elements of a MTM Service model version 2." In Medication Therapy Management Services. 2008

10

1.7 , ,

2. (A medication action plan) - , - ( C3THER ) - -

3. (Intervention and referral) - - ,

- - , - ,

,

- -

4. (Documentation and follow-up) - , -

Subjective observation, Objective, Assessment and Plan (SOAP Note)

- , , - (follow up)

5. ( Personal Medication Record: PMR) (Patient book) (Family Folder)

:

- , , - , - , - -

11

(Community Pharmacy Network Center)

[ : , , ]

(Medical Therapy Management: MTM)

1. (Medication therapy review) 2.

(A person medical record)

3. (A medication action plan) 4. (Intervention and referral) 5.

(Documentation and follow-up)

/

/

/

(Community Pharmacy Network Center)

PP

( )

1:

(DRPs),

( , , )

2:

(DRPs),

3: ,

,

/

12

1.

2. (Outcome)

3. (Pharmaceutical care for the community) (Home pharmaceutical care)

( )

1. 2. ( ) 3. 4.

1.

2. 3. (Family Pharmacist) 4. Medication Therapy Management: MTM 5. 6.

1. , ,

, ,

2. 3. (non-compliance) 4. 3 high alert drug 2

5.

13

1. 1

2.

3.

/

5:

6:

(M

edic

atio

n Th

erap

y Re

view

)

1:

2:

, ,

,

(Adhe

rence)

3:

(Medi

cation

Re

lated P

roblem

(s))

4:

1:

3: ,

2: (

DRPs

),

,

14

1. 1.1

1.2

1.3 ( .)

2. 2.1

2.1.1 2.1.2 ( .) 2.1.3

2.2 ( )

2.3 1

3. 2 3.1

3.1.1 3.1.2 3.1.3 3.1.4 (Foot Microfilament ) 3.1.5 3.1.6 3.1.7 3.1.8 3.1.9 (Patient Profile) 3.1.10 (Pharmacist Referral Assessment: RRA )

3.2 3.2.1 3.2.2 6 3.2.3 , 3.2.4

15

3.2.5 (Informed Consents Form) 3.2.6

4. 4.1

4.1.1 4.1.1.1 4.1.1.2 (Technical term) 4.1.1.3

(Communication Skill)

4.1.1.4 (Drug Identification Skill) 4.1.1.5 (Drug Related Problems) 4.1.1.6 4.1.1.7

4.2 4.2.1

4.2.2 4.2.3 4.2.4

4.3 4.3.1 4.3.2

4.4

4.4.1 . 4.4.2 4.4.3

4.4.4

4.4.5 .

16

4.5 4.5.1

1: 45 60

2: 20 40

3: 20 40

4 ( ): 20 - 40

4.5.2

3 4

1 2

4.6 4.6.1

4.6.2

4.6.3 .

.

. (Patient Knowledge Assessment)

. (Adherence Risk Assessment)

. (Foot Screening) .

17

.

. . .

(Pharmacist Referral Assessment: RRA)

4.7 4.7.1 (Pharmacist

Counseling Profile: RCP)

4.7.2 4.7.3 /

.

. (HHCREFER) .

. Pharmacy MTM

5. ( 18)

1. (Clinical symptoms) : Peripheral neuropathy, Peripheral retinopathy, Pitting edema

2. (Lifestyles)

: Uncontrolled diet (salty food), Less exercise, Smoking

3. (Drug Related Problems: DRPs) DRPs (Drug Related Problem Assessment Guideline: DAG)

18

(Dru

g Re

lated

Pro

blem

s Ass

essm

ent G

uide

line:

DAG

)

1. Un

treate

d in

dicati

on

()

1.1 (T

he p

atien

t is in

nee

d of

drug

ther

apy b

ut is

not r

eceiv

ing it.

)

1.2

(The

new

pro

blem

has n

ot be

en id

entifi

es o

r tre

ated.)

1.3

(The

conti

nuity

of d

rug

thera

py h

as b

een

inter

rupte

d.)

1.4

(The

pati

ent is

in n

eed

of pr

ophy

laxis

or p

reme

dicati

on.)

1.5

(The

pati

ent n

eeds

a sy

nerg

istic

or p

otenti

ating

dru

g the

rapy

.)

- CD

+ R

D

- CD

+ R

D

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

2. Im

prop

er d

rug

selec

tion

()

2.1(T

he d

rug

thera

py is

ineff

ectiv

e.)

2.2

(Rec

eive

drug

ther

apy t

hat c

ontra

indica

tions

exis

t.)

2.3

(Rec

eive

a pa

rticula

r dru

g the

rapy

in th

e pr

esen

ce o

f an

aller

gy to

that

drug

.)

2.4

(The

re e

xists

an e

quall

y effe

ctive

, safe

r dru

g tha

n tha

t pre

sentl

y bein

g us

ed.)

2.5

(The

re is

an

equa

lly e

ffecti

ve b

ut les

s exp

ensiv

e dr

ug a

vaila

ble.)

2.6

(The

pati

ent is

rece

iving

comb

inatio

n the

rapy

whe

n a

single

dru

g wo

uld b

e ex

pecte

d to

be e

quall

y effe

ctive

.)

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

3. Su

b

Ther

apeu

tic d

osag

e

()

3.1 (T

he d

ose

less t

han

optim

al.)

3.2

(Rec

eive

inapp

ropr

iate

dosin

g int

erva

l.) (T

oo lo

ng)

3.3

(R

eceiv

e ina

ppro

priat

e do

sage

form

.)

3.4

(Con

versi

ons t

o dif

feren

ce fo

rmula

tion

or b

rand

.)

3.5

(Rec

eive

the e

xpire

d or

dete

riora

ted d

rugs

.)

3.6

(C

onve

rsion

s to

differ

ence

route

.)

3.7

(A

pati

ents

dos

e is

decre

ased

rapid

ly.)(W

ithdr

awal)

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ R

D

4. Ov

er

dos

age

()

4.1 (T

he d

ose

is too

muc

h.)

4.2

(Rec

eiving

inap

prop

riate

dosin

g int

erva

l.) (to

o fre

quen

cy)

4.3

(R

eceiv

e ina

ppro

priat

e do

sage

form

.)

4.4

(C

onve

rsion

s to

differ

ence

form

ulatio

n or

bra

nd.)

4.5

(C

onve

rsion

s to

differ

ence

route

.)

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

19

: P

= Ph

arma

cist (

)

CD

=

Cons

ult D

octor

()

RD

=

Refer

ral to

Doc

tor (

)

: 1.

Stra

nd L

M, M

orley

PC,

Cipo

lle R

J, Ra

msey

R, L

amsa

m GD

. Dru

g-re

lated

pro

blems

: the

ir str

uctur

e an

d fun

ction

. DIC

P 19

90; 2

4 (1

1): 1

093

1097

.

2. Ph

arma

ceuti

cal C

are

Netw

ork E

urop

e Fo

unda

tion.

PCNE

Clas

sifica

tion

for D

rug

relat

ed p

roble

ms V

5.01.

Zuidl

aren

: May

200

6

5. Ad

verse

dru

g re

actio

n

()

5.1

(Side

effe

cts

Type

A A

DR)

5.2

(Dru

g all

ergy

T

ype

B AD

R)

- P

() +

CD

- P

() +

CD

6. Dr

ug in

terac

tion

()

6.1

(Dru

g

drug

inter

actio

ns)

6.2

(Dru

g

food

inter

actio

ns)

6.3

(Dru

g

disea

se in

terac

tions

)

- P

(/

) + C

D

- P

(/

) + C

D

- P

(/

) + C

D

7. Inv

alid

indica

tion

(

)

7.1

(Dru

g ab

use)

7.2

(Dru

g de

pend

ence

)

7.3

(Use

the

drug

with

out in

dicati

on)

- P (

/) +

CD

- P (

/) +

CD

- P (

/) +

CD

8. No

n

comp

lianc

e

()

8.1

8.2

8.3

8.4

(

,

)

8.5

8.6

(

/)

8.7

(/

)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

9. Di

spen

sing

erro

r

()

9.1

(Inco

rrect

patie

nt na

me)

9.2

(Wro

ng d

rug

erro

r)

9.3

(Wro

ng d

osag

e for

m er

ror)

9.4

(Wro

ng d

rug

stren

gth e

rror)

9.5

(Wro

ng d

rug

quan

tity e

rror)

- P

() +

RD

()

- P

() +

RD

()

- P

() +

RD

()

- P

() +

RD

()

- P

() +

RD

()

20

1. Untreated indication ( ) 1.1 (The patient is in need of drug therapy but

is not receiving it.) : Dizziness and Uncontrolled HTN (BP = 180/110 mmHg, p = 75)

Hypertension

1.2 (The new problem has not been identifies or treated.)

: DM Peripheral retinopathy > 2 1.3 (The

continuity of drug therapy has been interrupted.) : HTN Hypovolumic shock

Dopamine

1.4 (The patient is in need of prophylaxis or premedication.)

: Peptic ulcer Ischemic stroke Aspirin 81 mg (secondary prevention)

peptic ulcer

1.5 (The patient needs a synergistic or potentiating drug therapy.)

: Niclosamide laxative

2. Improper drug selection ( ) 2.1 (The drug therapy is

ineffective.) : LDL cholesterol Gemfibrozil 300 mg 1 x 1 ac

2.2 (Receive drug therapy that contraindications exist.) : stimulant laxative

2.3 (Receive a particular drug therapy in the presence of an allergy to that drug.) : Penicillin Amoxicillin

2.4 (There exists an equally effective, safer drug than that presently being used.) : Metformin severe renal insufficiency

21

2.5 (There is an equally effective but less expensive drug available.) : LDL cholesterol Rosuvastatin (Crestor)

2.6 (The patient is receiving combination therapy when a single drug would be expected to be equally effective.) : NSAIDs 2 Ibuprofen Diclofenac

Osteoarthritis

3. Sub Therapeutic dosage ( ) 3.1 (The dose less than optimal.)

: 50 . Amoxicillin 125 mg 1x4 ac & hs 3.2 (Receive inappropriate dosing interval.) (Too long)

: Parkinson Madopar 250 mg x 2 Tremor Parkinson

3.3 (Receive inappropriate dosage form.) : COPD Seretide accuhaler

3.4 (Conversions to difference formulation or brand.) : phenytoin suspension capsule ( bioavailability )

3.5 (Receive the expired or deteriorated drugs.) 3.6 (Conversions to difference route.)

: DM Regular Insulin IV 20 0 20 IU

Regular insulin SC 20 0 20 IU

3.7 (A patients dose is decreased rapidly.) (Withdrawal) : Lorazepam 4 mg 1 x 1 hs 2 mg x 1 hs

4. Over dosage ( ) 4.1 (The dose is too much.)

: Metformin 850 mg 2 x 3 pc (Maximum dose = 2,550 mg/day)

22

4.2 (Receiving inappropriate dosing interval.) (Too frequency) : Glibenclamide 5 mg 1 x 3 ac Hypoglycemia

(Duration of action = 12 24 hrs)

4.3 (Receive inappropriate dosage form.) : Seizure maintenance phase Phenytoin 50 mg 2 x 3 pc

Phenytoin 100 mg Extended Release 2 x 3 pc (Maintenance

phase maximum dose = 600 mg/day)

4.4 (Conversions to difference formulation or brand.) : Anemia Ferrous Sulfate 200 mg 1 x 3 pc (elemental iron 20%)

Ferrous Fumarate 200 mg 1 x 3 pc (elemental iron 33%)

4.5 (Conversions to difference route.) : Penicillin-G 24,000,000 unit Penicillin-V

24,000,000 unit (Maximum = 4,800,000 unit, 3 g)

5. Adverse drug reaction ( ) 5.1 (Side effects Type A ADR)

: Enalapril 5.2 (Drug allergy Type B ADR)

: SJS Gabapentin

6. Drug interaction ( ) 6.1 (Drug drug interactions)

: Simvastatin Gemfibrozil (Rhabdomyosis) 6.2 (Drug food interactions)

: Norfloxacin (Decrease Norfloxacins effect) 6.3 (Drug disease interactions)

: Hyperthyroid Warfarin (Increase Warfarins active metabolite)

7. Invalid indication ( )

7.1 (Drug abuse) : (Metformin + Acarbose + Thyroxine)

23

7.2 (Drug dependence) : Lorazepam 4 mg 6

7.3 (Use the drug without indication) : DM Cloxacillin 500 mg 1 x 4 pc

Re-medication Cloxacillin

8. Non - Compliance ( ) 8.1

: Insulin 15 0 15 IU 30 0 0 IU 8.2

: Simvastatin 8.3

: HCTZ 8.4 ( , )

: DM DM 8.5

: 8.6 ( / )

: (Steroid induced peptic ulcer)

8.7 ( / ) : Insulin

9. Dispensing error ( ) 9.1 (Incorrect patient name) 9.2 (Wrong drug error)

: Enalapril 20 mg 1 x 1 pc Simvastatin 20 mg

9.3 (Wrong dosage form error) : Isosorbide dinitrate 5 mg SL 1 tab prn Isosorbide

mononitrate 20 mg

9.4 (Wrong drug strength error) : Metformin 500 mg 2 x 2 pc Metformin 850 mg

9.5 (Wrong drug quantity error) : Metformin 500 mg 1 x 2 pc 120 ( 2

) 90 ( )

24

(Problems)

1. Clinical symptoms : (Technical term) : Peripheral neuropathy, Peripheral retinopathy, Pitting edema

2. Lifestyles : (Technical term)

: Uncontrolled diet (salty food), Less exercise, Smoking 3. DRPs

1. Untreated indication ( )

1.1 : Dizziness and Uncontrolled HTN (BP = 180/110 mmHg, p = 75)

1.2 : Peripheral retinopathy (> 2 years)

1.3 : Amlodipine 10 mg 1 x 1 pc (Uncontrolled HTN)

1.4 : Aspirin 81 mg (secondary prevention Ischemic stroke)

1.5 : Niclosamide laxative

(Problems)

Clinical Symptoms:

1.

2.

Lifestyles:

1.

2.

DRPs:

1.

2.

(Actions)

1.

2.

(Results)

1.

2.

F/U: Clinical Symptoms:

1.

2.

F/U: Lifestyles:

1.

2.

F/U: DRPs:

1.

2.

25

2. Improper drug selection ( )

2.1 : Gemfibrozil 300 mg 1 x 1 ac (High LDL Cholesterol)

2.2 : Stimulant laxative (Pregnancy)

2.3 : Amoxicillin 500 mg 1 x 4 ac & hs (Allergy)

2.4 : Metformin 500 mg 1 x 3 pc (severe renal insufficiency)

2.5 : Rosuvastatin (Crestor) 1 x 1 pc (LDL Cholesterol = 102 mg/dl)

2.6 : Ibuprofen 400 mg + Diclofenac 50 mg (Osteoarthritis)

3. Sub Therapeutic dosage ( )

3.1 : Amoxicillin 125 mg 1 x 4 ac & hs (Weight of patient = 60 Kg)

3.2 : Madopar 250 mg x 2 (Sign of Parkinson)

3.3 : Seretide accuhaler (Elderly; age = 85 years)

3.4 : Phenytoin suspension Phenytoin capsule ( )

3.5 : Insulin 70/30 (Exp. 1/2009)

3.6 : Regular Insulin I.V. 20 0 20 IU Regular insulin S.C. 20 0 20 IU

(Uncontrolled diabetes)

3.7 : Lorazepam 4 mg 1 x 1 hs 2 mg x 1 hs (Insomnia)

4. Over dosage ( )

4.1 (The dose is too much.) : Metformin 850 mg 2 x 3 pc (Maximum dose = 2,250 mg/day)

4.2 : Glibenclamide 5 mg 1 x 3 ac Hypoglycemia

26

4.3 : Phenytoin 50 mg 2 x 3 pc Phenytoin 100 mg ER 2 x 3 pc (Maintenance

phase maximum dose = 600 mg/day)

4.4 : Ferrous sulfate 200 mg 1 x 3 pc Ferrous fumarate 200 mg 1 x 3 pc

4.5 : Penicillin-G I.V. 24,000,000 unit Penicillin-V 24,000,000 unit (Maximum =

4,800,000 unit, 3 g)

5. Adverse drug reaction ( )

5.1 : Enalapril 20 mg 1 x 1 pc (Dry cough)

5.2 : Gabapentin (SJS)

6. Drug interaction ( )

6.1 : Simvastatin 10 mg 1 x 1 pc + Gemfibrozil 2 x 1 ac (Rhabdomyosis)

6.2 : Norfloxacin 400 mg 1 x 2 pc + (Decrease Norfloxacins effect)

6.3 : Warfarin + Hyperthyroid (Increase Warfarins active

metabolite)

7. Invalid indication ( )

7.1 : Metformin + Acarbose + Thyroxine ( )

7.2 : Lorazepam 4 mg (> 6 months) Insomnia

7.3 : Cloxacillin 500 mg 1 x 4 pc (Non Infection)

8. Non - Compliance ( )

8.1

( , ) : Metformin 500 mg 1 x 2 pc 1 x 1 pc

27

8.2

( , ) : Glibenclamide 5 mg 1 x 2 ac ( )

Metformin 500 mg 1 x 3 pc ( ) 8.3

( , (Off)) : HCTZ 50 mg 1 x 1 pc (Off)

Aspirin 81 mg 1 x 1 pc (Off) 8.4 ( , )

( , ) : Amlodipine 10 mg 1 x 1 pc

HCTZ 50 mg 1 x 1 pc 8.5

( ) : 1 2553

9 2553 8.6 ( / )

( , ) : HCTZ 50 mg 1 tab prn

Atenolol 50 mg 1 x 1 pc + Metoprolol 100 mg 1 x 1 pc + Propranolol 10 mg 1 x 1 pc 3

8.7 ( / )

( , ) : Seretide accuhaler 1 puff

Aspirin 81 mg 1 x 1 pc + Warfarin 5 mg 1 x 3 pc

9. Dispensing error ( ) 9.1 (Incorrect patient name) 9.2 (Wrong drug error)

( , ) : Enalapril 20 mg 1 x 1 pc Simvastatin 20 mg

9.3 (Wrong dosage form error) ( , )

: Isosorbide dinitrate 5 mg SL 1 tab prn Isosorbide mononitrate 20 mg

28

9.4 (Wrong drug strength error) ( , )

: Metformin 500 mg 2 x 2 pc Metformin 850 mg 9.5 (Wrong drug quantity error)

( , , ) : Metformin 500 mg 1 x 2 pc # 120 tab # 90 tab

(Actions)

1. (Comprehensive medication review/drug use evaluation) : Medication review

2. (Consultation): : Consulted doctor: - Adverse drug reaction of Enalapril

3. (Counseling): (Patient) (Caregiver) : Patient counseling: - Adverse drug reaction of Enalapril

- Sign of postural hypotension

4. (Education): (Patient) (Caregiver) : Educated patient: - Control diet (sweet)

-

5. (Referral patients) ( )

: Referral patient ...... - Uncontrolled hypertension (BP = 201/110 mmHg, p = 65)

(Results)

1. Drug therapeutic plan 1.1

: Stop therapy 1.2

: Start new therapy 1.3

( , )

: Enalapril 20 mg 1 x 1 pc (Off)

1.4 ( , , )

: Changing drug: - Enalapril 20 mg 1 x 1 pc Losartan 50 mg 1 x 1 pc

29

1.5 ( , , )

: Changing dose: - Enalapril 5 mg 1 x 1 pc Enalapril 20 mg 1 x 1 pc - Simvastatin 40 mg 1 x 1 hs Simvastatin 10 mg 1 x 1 hs

1.6 ( , , , , )

: Changing dosage form: - Phenytoin 50 mg 2 x 3 pc Phenytoin 100 mg ER 1 x 1 pc

1.7 ( , , )

: Changing drug use: - ISDN SL 5 mg 1 tab prn Ismo 20 mg 1 x 2 pc

2. Compliance 2.1

( Good compliance) : DRPs:

1. Good compliance - HCTZ 50 mg (Off) 1 x 1 pc

2.2 ( No change compliance)

: DRPs: 1. No change compliance

- HCTZ 50 mg (Off) (Off)

2.3 ( Poor compliance)

: DRPs: 1. Poor compliance

- Metformin 500 mg 1 x 3 pc 1 x 1 pc (Off)

6. ( 1 49)

(Medication

Therapy Management: MTM)

30

7.

(Peripheral neuropathy)

9 14

(peripheral vascular disease)

(foot deformities)

(callus)

10

fasting plasma glucose (FPG)

Hemoglobin A1c (HbA1c)

(diabetic nephropathy)

9. Crawford F, Inkster M, Kleijnen J, Fahey T. Predicting foot ulcers in patients with diabetes: a systemic review and meta-analysis. QJM

2007; 100: 65 86

31

10

10

1.

2. (self foot care) (

)

3. 4.

1. 1 2.

1. 2. 6 12 3. 4.

10. McIntosch A, Peters JR, Young Rj, et al. Prevention and management of foot problems in type 2 diabetes: Clinical guidelines and evidence 2003. (full NICE guideline). Sheffield: University of Sheffield. www.nice.org.uk

11. McIntosch A, Peters JR, Young Rj, et al. Prevention and management of foot problems in type 2 diabetes: Clinical guidelines and evidence 2003. (full NICE guideline). Sheffield: University of Sheffield. www.nice.org.uk

12. Sriussadaporn S, Mekanandha P, Vannasaeng S, et al. Factors associated with diabetic foot ulceration in Thailand: a case control study. Diabet Med 1997; 14: 50 6

13. American Diabetes Association. Standards of medical care in diabetes 2007. Diabetes care 2007; 30 (Suppl 1): S4 41 14. Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM. Preventive foot care in people with diabetes (Technical Review). Diabetes

Care 1998; 21: 2161 77

32

1. 2. 6 3. 4. /

( /

)

5. 15

1. ( ) 2.

(ingrown toenail)

( )

3. ( ) ( gangrene)

(callus)

4. (deformity) neuropathy hallux valgus, hallux varus, claw toe, hammer toe, (bony prominence) Charcot foot

5. (gait) (mobility)

6. (claudication) femoral ( ), dorsalis pedis (

) posterior tibial ( ) 2

7. ( 38)

15. Sriussadaporn S, Ploybutr S, Nitiyanant W, Vannaseang S, Vichayanrat A. Behavior in self care of the foot and foot ulcers in Thai non insulin dependent diabetes mellitus. J Med Assoc Thai 1998; 81: 29 36

33

8. neuropathy monofilament 5.07 10 g

9, 16 18 (

Monofilament 36)

19

ulcer

(sloughing or shedding) (necrotic tissue)

(purulent exudates)

(pressure sore)

(sacrum)

(gangrene) (venous insufficiency)

- 2 dry gangrene

wet

gangrene

2 20

1.

( 1 3 )

16. Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on foot re ulceration in patients with diabetes. A randomized controlled trial. JAMA 2002; 287: 2552 9

17. Rith Najarian SJ, Stolusky T, Gohdes DM. Identifying diabetic patients at high risk for lower extremity amputation in a primary health care setting. A prospective evaluation of simple screening criteria. Diabetes Care 1992; 15: 1386 9

18. Pharm H, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A. Screening techniques to identity people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care 2000; 23: 606 11

19. Pacaud D, Singer D, McConnell B, Yale J-F. Assessment of screening practices for peripheral neuropathy in people with diabetes. Can J Diab Care 1999; 23: 21 5

20. Stephen M Schroeder, Peter. Blume. Foot Infections. [online]. 2002 [cited 2010 Aug 30]. Available from: URL: http://emedicine.medscape.com/article/1237208-overview#DiabeticFootInfections

34

1

2.

2.1

2-4

2.2

2.3

2.4

2.5

35

21

2

( )

( )

( ) () (

)

( )

( )

( )

21. . . . . [online]. 2002 [cited 2010 Aug 30]. Available from: URL: http://www.pharmacy.msu.ac.th/pharm/w213.pdf

36

Monofilament ( 5.07 10 g)

Monofilament light touch deep pressure

Monofilament ( g) Monofilament Monofilament

Monofilament Monofilament

5.07 10 g (protective sensation)

(reproducibility) 22

Monofilament 1. Monofilament (Disposable monofilament)

2. Monofilament

3. Monofilament Monofilament 2 Monofilament

4. Monofilament 10 ( 1 10 ) 100 24 Monofilament

Monofilament

1. 10

2. callus,

22. , . : , ,

. Diabetes Mellitus. 1. : ; 2548: 583 608

37

Monofilament 5.07 10 g

1. 2. Monofilament

(forearm) Monofilament

1 1.5

3. 4. 5. Monofilament Monofilament

1 1.5 ( ) Monofilament

Monofilament

(Real application Monofilament

) (Sham application Monofilament

monofilament ? ?)

6. ( )

protective sense

7. ()

8.

9. 10 2 10. Protective

sensation (insensate foot)

38

23

1. 2

2. 2

3. metatarso phalangeal 1 4. 1/2 1 5. (forefoot) metatarso phalangeal

joint

(claw hammer toe)

6. 7. Velcro

8.

9.

23. Klenerman L, McCabe C, Cogley D, Crerand S, Laing P, White M. Screening for patients at risk of diabetic foot ulceration in a general diabetic outpatient clinic. Diabet Med 1996; 13: 561 3

39

8.

(Compliance)

. .

(Trantheoretical Stage of Change Modeal)

(Stage of

Change) 6

Stage of changes24 26 1. Precontemplation ( )

:

:

: 6 1

2. Contemplations ( ) :

:

-

: 6

24. Stages of Change - [online] ; 2010 [Accessed on August 10 , 2010] Available at URL:

office.bangkok.go.th/doh/daptd/Article/article_07.doc

40

3. Preparation ( ) :

:

: 1

4. Action ( ) :

:

: 6

5. Maintenance ( ) :

:

: 6 5

6. Termination ( ) :

:

: 5

25. Stage of Change [online] ; 2010 [Accessed on August 10 , 2010] Available at URL:

http://gotoknow.org/blog/chage/210405 26. (Transtheoretical Stage of Change Model) ; 2010 [Accessed on August 10 , 2010] Available at URL:

http://visitdrsant.blogspot.com/2010/01/transtheoretical-stage-of-change-model.html

41

(Process of Change)27 - 29

10

1) (Conscious raising)

2) (Dramatic relief)

(Role play)

3) (Self reevaluation)

4) (Social reevaluation)

5) (Self liberation )

27. Prochaska, J.O. (1979). Systems of Psychotherapy: a Transtheoretical Analysis. Pacific, CA:Brooks-Cole.

42

6) (Social liberation)

7) (Counter condition)

8) (Stimulus control)

9) (Contingency management)

10) (Helping relationship)

, , ,

28. Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical therapy toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19(3), 276-287.

29. Prochaska, J.O., Norcross, J.C., & DiClemente, C.C. (1994). Changing for Good. New York, NY: William Morrow.

43

9.

1) :

68 , Glibenclamide 5 mg 1x2 ac, Metformin 500 mg 1x3 pc, Enalapril 5 mg 1x2 pc

44

:

:

:

:

2) :

3) :

50 , Glimepiride 4mg 1x1 ac

, Metformin 500mg 1x3 pc, Hydrochlorothiazide 25 mg 1x1 pc

:

:

:

4) :

60

:

2

:

5) : 4

45

10.

X A A

X

A Y B B

Y B

Z C C

C

A B

C D

X

( X, Y Z)

Y

B

Z

A

D

46

5

1. (Finding Problems)

(Problem list)

2. (Clarify) (Drug related

problems; DRPs), (Lifestyle) , ,

3. (Setting Goals)

(Untreated indication)

4. (Prioritize)

5

1. (Immediate) 24

47

2. (Urgent)

2 3. (Soon)

6

4. (non-urgent pharmacists note)

1. (immediate) / (urgent) Untreated indication:

1. (The patient is in need of drug therapy but is not receiving it.)2. (The new problem has not been identifies or treated.)3. (The continuity of drug therapy has been interrupted.)

Improper drug selection: 1. (The drug therapy is ineffective.) 2. (Receive drug therapy that contraindications exist.) 3.

(Receive a particular drug therapy in the presence of an allergy to that drug.) 4.

(There exists an equally effective, safer drug than that presently being used.)

Sub therapeutic dosage: 1. (The dose less than optimal.) 2. (Receive inappropriate dosage form.) 3.

(Conversions to difference formulation on brand.) 4. (Receiving the expired or deteriorated drug.) 5. (A patients dose is decreased rapidly,)

(Withdrawal)

Over dosage: 1. (The dose is too much.) 2. (Receiving inappropriate dosage form.) 3.

(Conversions to difference formulation on brand.)

48

Adverse drug reaction (ADRs): 1. (Drug allergy Type B ADR)

Dispensing errors: 1. (Incorrect patient name.) 2. (Wrong drug error.) 3. (Wrong dosage form error.) 4. (Wrong drug strength error.)

Uncontrolled Diseases / Exacerbation

2. (urgent) / (soon) Untreated indication:

1. (The patient is in needs of prophylaxis or premedication.)

Adverse drug reactions (ADRs): 1. (Side effects Type A ADR)

Drug Interactions (DIs): 1. (Drug Drug interactions) 2. (Drug Disease interactions)

3. (soon) / (non-urgent) Untreated indication:

1. (The patient needs a synergistic or potentiating drug therapy.) Improper drug selection:

1. (There is an equally effective but less expensive drug available.)

2. (The patient is receiving combination therapy when a single drug would be expected to be equally effective.)

Sub therapeutic dosage: 1. (Receiving inappropriate dosing interval.)(Too long) 2. (Conversions to difference route.)

Over dosage: 1. (Receiving in appropriate dosing interval.)(Too frequency) 2. (Conversions to difference route.)

Drug Interactions (DIs): 1. (Drug food interaction.)

Dispensing errors: 1. (Wrong drug quality error.)

49

Non compliance 1. 2. 3. 4. ( , ) 5. 6. ( / ) 7. ( / )

Lifestyle (Consumption / Exercise / Stress condition / Environment)

11. 1. (Self care)

Self-Care

2. (Self medication) Self medication Self care (Communicator)

3.

4.

5.

:

( 3 89)

50

1

2

3

4

(Patient profile)

51

1

(Pharmaceutical Care Profile Users Guide)

52

(Pharmaceutical Care Profile Users Guide)

(Pharmaceutical Care Profile)

(Home Health Care)

1. 2.

6 1. (Informed Consent Form)

1.1 (Informed Consent Form: ICF-HHC) 1.2 (Participant Information Sheet: PIS-HHC)

2. (Profile) 4

2.1 (Patient Health Profile: PHP) 2.2 (Patient Medication Profile: PMP) 2.3 (Pharmacist Screening Profile: RSP) 2.4 (Pharmacist Counseling Profile: RCP)

3. (Assessment) 2

3.1 (Patient Medication Questionnaire Assessment: PMA) 3.2 (Patient Knowledge Assessment: PKA)

4. (Guideline) 1

4.1 (Drug Related Problems Assessment Guideline: DAG)

5. (Pharmacist Referral Assessment: RRA) 2

5.1 (Pharmacist Referral Assessment: RRA) 5.2 (Physician Responded Form: PRF)

6.

6.1 6.2 6.3 (Patient Record Book: PRB)

53

,

2.1 R Registered Pharmacist

P Patient

2.2 PMP = Patient Medication Profile (Medication)

2.3 A Assessment

E Education

G Guideline /

P Profile /

13 3 ( )

1 2 ->

2 6 2

1: 2 ->

2: 4 ->

3 5 ->

- - 1 2 3

1. 1 2 . . 2553 53

2. 2 2.1 2 2

. . 2552 52

2.2 4 ( ) 3. 3 99

00099

- -

5 3 5 2 1 0 0 1 0 0 0 9 9

54

1

(Informed Consent Form)

55

(Informed Consent Form)

. . 2554

. 0-2538-4906, 08-9141-9371

56

(Participant Information Sheet)

:

: ( )

: . , .

: 1209 94 . . 10310

: 0-2934-4874, 0-2538-4906 : 08-9947-5511, 08-9141-9371 E-mail: [email protected]

(Drug related problems)

,

2

(non-compliance) ,

,

2

1.

2.

3.

, 700

57

1. , / 2.

:

1. , ,

2. 1 ,

3. 1 4.

30 60

. , .

.

( )

58

2

(Profile)

59

2. (Profile) 2.1 (Patient Health Profile: PHP) 6

PHP1:

PHP2:

PHP3:

PHP4:

PHP5:

PHP1:

PHP2:

PHP3: 2 1:

/ / /

/

2: ( )

PHP4: 2

1: /

/ ( )

2: Chief complaint

PHP5:

(

)

60

(Patient Health Profile: PHP) PHP 1:

---- / / 12 / 10 / 2495 57 : 041 63 71

10230 08 9987 6543

15:

/

1. 2. 3.

: - 08 9989 8989

63

PHP 2:

1. ( / )

2. ( )

/ . / .

3. / / /

/ / ( )

4. / / /

5. ( ) < 10,000 10,000 30,000 30,001 50,000 > 50,000

6. ( ) < 10,000 10,000 50,000 > 50,000

7

1

1 2 3 4 5 6 7 8 9 0 1 0 1

- - 5 3 5 2 1 0 0 1 0 0 0 9 9

61

PHP 3:

( / ) ( )

( / )

( 1 / )

( / )

( / )

/ ( 1 / )

( )

/

6 23.00 05.00 .

( )

-

-

-

-

- 1 ( )

- ( )

- ,

( )

:

/ /

- - 5 3 5 2 1 0 0 1 0 0 0 9 9

62

PHP 4:

/

( ) PHP 5:

Peripheral neuropathy 2545 / 5 ,

- -

- -

Ischemic stroke 2550 / 2

- -

- -

- - ( )

- -

- -

- -

1. - -

2. - -

Chief complaint:

Visit 1: Pitting edema (2+) both legs

Visit 2:

Visit 3:

/ /

- - 5 3 5 2 1 0 0 1 0 0 0 9 9

63

2.2 (Pharmacist Medication Profile: RMP) / /

/ /

2

RMP1: / /

RMP2: / /

(

2 /

/ )

1.

2. 3.

4. (Patient Medication Questionnaire Assessment: PMA)

(Drug Related Problems Assessment Guideline: DAG)

64

/ /

(Pha

rmac

ist M

edica

tion

Prof

ile; R

MP 1)

/

( )

1 /

9 /

52 .

4 / 9

/ 52

.

14 /

9 /

52

.

/

/

.

/

/

.

/

/

.

/

/

.

/

/

.

1 Me

tform

in 50

0 m

g1x

2 pc

10 (1

) 60

(71)

46 (1

) / +

2

2

3

4

5

6

7

8

9

10

11

12

13

14

15

4 / 9

/ 255

2

:

:

1 2

14

:

14

= 2

x 13 =

26

: 71

26

= 45

46 +

(1) =

47

: 14

47 4

5 = 2

(

+

,

)

-

-

5 3

5

2 1 0

0 1

0 0

0 9

9

65

/ /

(Pha

rmac

ist M

edic

atio

n Pr

ofile

; PM

P 2)

/

1 Am

oxic

illin

500

mg

1 x

4 ac

& h

s

2 Ce

tirizi

ne 1

0 m

g 1

x 1

pc

-

3

()

3

-

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

-

-

5 3

5

2 1 0

0 1

0 0

0 9

9

66

2.3 (Screening Profile: RSP) ( )

( ) ( )

2

RSP1:

RSP2: (Foot Screening)

1. RSP1

1.1 ()

1.2

2. RSP2 ( Neuropathy monofilament) 2.1 ( )

/

2.2

1 5

(FBS, Postprandial) HbA1c

67

(Pha

rmac

ist S

cree

ning

Pro

file:

RSP

1)

/ /

1

/

9

/

255

3

.

/

/

.

/

/

.

/

/

.

/

/

.

Kg

-

Cm

-

BMI

%

18

23

BP

mm

Hg

< 12

0 / 8

0 13

5 / 8

9 13

9 / 9

2 (5

/ 8

/ 52)

HR

Bpm

70

8

0 87

92

(5 /

8 / 5

2)

FBS

mg

/ dl

70

110

Postp

rand

ial 2

hr

mg

/ dl

< 20

0

HbA1

c %

6

7

TC

mg

/ dl

< 20

0

180

(5 /

8 / 5

2)

TG

mg

/ dl

< 15

0

130

(5 /

8 / 5

2)

LDL-

C m

g / d

l <

100

HDL-

C m

g /

dl >

40

BUN

mg

/ dl

7

20

SCr

mg

/ dl

0.5

1.

5

CrCl

m

l / m

in / 1

.73

m2

90

140

Uric

acid

mg

/ dl

< 7

Albu

min

g / d

l 3.

2

5.0

AST

IU /

L <

35

ALT

IU /

L <

35

Alk.

Phos

. IU

/ L

35

130

Tota

l bilir

ubin

mg

/ dl

0.1

1.

2

Dire

ct bil

irubin

m

g / d

l 0

0.

3

.

:

-

-

5

3 5

2 1

0 0 1

0

0 0 9

9

68

(Pharmacist Screening Profile: RSP 2)

1 : 1 / 9 / 2552 .

- Peripheral neuropathy .

- Pitting edema both legs .

.

.

.

.

.

.

.

.

2 : 14 / 9 / 2552 .

.

.

.

.

.

.

.

.

.

.

: / / .

.

.

.

.

.

.

.

.

.

( )

- - 5 3 5 2 1 0 0 1 0 0 0 9 9

69

2.4 (Counseling Profile: RCP)

/

2

RCP 1:

RCP 2:

1. RCP 1 3 Lifestyles, Clinical Symptoms DRPs

Lifestyles: Clinical Symptoms: Peripheral neuropathy DRPs: 1. Compliance

1.1

- Metformin 500 mg 1 X 2 pc 1 X 1 pc

2. Keyword Technical term

3. ( 1) RCP 1 RCP 2

4. Good

Poor

No Change

Lifestyles: No change

Clinical symptoms: Peripheral neuropathy Good

DRPs: 1. Non compliance 1.1

- Metformin 500 mg 1 X 2 pc 1 X 1 pc Good

5. RCP1 Keyword Technical Term

1. (Comprehensive medication review/drug use evaluation)

: Medication review

2. (Consultation):

: Consulted doctor: - Adverse drug reaction of Enalapril

70

3. (Counseling): (Patient) (Caregiver)

( )

: Patient counseling: - Adverse drug reaction of Enalapril

: Dry cough -> sometimes

- Postural hypotension

: Sometimes ->

4. (Education): (Patient) (Caregiver)

: Educated patient: - Control diet (sweet)

-

5. (Referral patients)

( )

: Referral patient ......

- Adverse drug reaction of Enalapril (Dry cough)

- Uncontrolled hypertension (BP = 201/110 mmHg, p = 65)

6. RCP2 Keyword Technical term RCP1 3

Lifestyles, Clinical Symptoms DRPs

F/U: Lifestyles: , F/U: Clinical Symptoms: Peripheral neuropathy F/U: DRPs: 1. Compliances

1.1


7. RCP1 RCP2 /

8.

/

71

(Pharmacist Counseling Profile: RCP)

RCP1: , RCP2:

1 : 1 / 9 / 2552 .

(Lifestyles, Clinical symptoms, DRPs)

Lifestyles: 1. Uncontrolled diet (sweet)

2. Alcohol intake (1 bottle/day)

Clinical symptoms: 1. Peripheral neuropathy

2. Pitting edema both legs

3. Dry cough

4. Uncontrolled hypertension

(BP = 201/110 mmHg, p = 65)

DRPs :

8. Non compliances

8.1


5. Adverse drug reactions (ADRs)

5.1

- Enalapril 5 mg 1 X 1 pc (Dry cough)

(Actions)

1. Medication review

2. Educated patient:

- Control diet (sweet)

-

3. Patient counseling:

- Adverse drug reaction of Enalapril

: Dry cough -> sometimes

4. Referral patient: .

- Uncontrolled hypertension with ADRs (enalapril)

(BP = 201/110 mmHg, p = 65)

(Plans)

- F/U: Referral patient: .

- Uncontrolled hypertension with ADRs (enalapril)

(BP = 201/110 mmHg, p = 65)

- F/U: Lifestyles: 1. Uncontrolled diet (sweet)

2. Alcohol intake (1 bottle/day)

- F/U: Clinical symptoms: 1. Peripheral neuropathy

2. Pitting edema both legs

3. Dry cough

4. Uncontrolled hypertension

(BP = 201/110 mmHg, p = 65)

- F/U: DRPs:

8. Non compliances

8.1


5. Adverse drug reaction (ADRs)

5.1

- Enalapril 5 mg 1 X 1 pc (Dry cough)

.

- - 5 3 5 2 1 0 0 1 0 0 0 9 9

72

3

(Assessment)

73

3. (Assessment) 3.1 (Patient Medication Assessment: PMA)

3

PMA1:

PMA2:

PMA3: (Adherence Risk

Assessment)

1. PMA1 PMA2 PMA3

2. PMP PMA1

(Patient Medication Profile: PMP)

3. (Adherence Risk Assessment) (PMA3)

1. 2.

3.

: PMA1 PMA2

74

(Pat

ient

Med

icat

ion

Ques

tionn

aire

Ass

essm

ent:

PMA)

* PM

A1:

7

:

a.

//

b.

c.

d.

**

e.

/ **

f.

g.

-**

h.

-***

/

1.

2.

3.

:

1.

2.

3.

1.

2.

3.

4.

:

0.

1.

2.

3.

4.

1 M

etfo

rmin

50

0 -

1 1

pc

1-

1

1 0

-

2

3

4

5

6

7

8

9

10

11

12

/ /

.

:

1a

1h

( R

MP1

)

: 1

, 2

3

1

Met

form

in

-

-

5

3 5

2 1

0 0

1 0

0 0

9 9

75 PM

A2:

:

a. /

()

b. /

c.

d.

e.

()

f. (

)

g.

h. (

)

i.

()

j.

k.

l.

(

) m.

......

......

......

......

......

......

......

......

......

......

......

......

......

......

n. ...

......

......

......

......

......

......

......

......

......

......

......

......

......

...

o. ...

......

......

......

......

......

......

......

......

......

......

......

......

......

...

p. ...

......

......

......

......

......

......

......

......

......

......

......

......

......

...

-

-

5 3

5

2 1 0

0 1

0 0

0 9

9

76

PMA3: (Adherence Rick Assessment)*

:

1 =

0 =

1. Regimen non-adherence ( a e PMA1 ) 1.1

(Patient Medication Profile : PMP) 1a 1

1.2 1b 1 1.3 / 1c,1d 0 1.4 / 7 1e 0 1.5 1b,1c,1d 0 1.6 1 1a,1b,1c,1d,1e 1 1.7 1 1a, 1b,1c,1d,1e 1

Regimen non-adherence (Score of 1 indicates Positive screen for Regimen non adherence)

4 2. Negative beliefs or motivational barriers ( g h PMA1 )

2.1 1g 1 2.2 1h 0

Negative beliefs or motivational barriers (Score of 1 indicates Positive screen for Negative beliefs or motivational barriers)

1 3. Recall Barriers ( c PMA1 h PMA2 )

3.1 1 2 1c 1 3.2 2h 1

Recall Barriers (Score of 1 indicates Positive screen for Recall barriers)

2 4. Access Barriers ( j l PMA2 )

4.1 2j 1 4.2 2k 0 4.3 2l 0

Access Barriers (Score of 1 indicates Positive screen for Access barriers) 1

*Adapted from: Svarstad et al (1998) Total scores 8 . / /

- - 5 3 5 2 1 0 0 1 0 0 0 9 9

77

3.2 (Patient Knowledge Assessment: PKA)

2

PKA1: 5

PKA2:

1. PKA1 ( 5 )

- ...... ? ( )

2. PKA1 ( 6: )

3. PKA2 ( )

1. Subjective data Objective data

2.

78

(Patient Knowledge Assessment: PKA) PKA1:

1. 1.1

1.2

1.3

2. 2.1

2.2 ( )

2.3

3. 3.1

4.

4.1

4.2

4.3

4.4

4.5

6. ( ) 6.1 ( )

6.2

6.3

PKA2:

1. (Visit 2) 2. (Visit 3) 3. 4. 5. 6.

/ /

- - 5 3 5 2 1 0 0 1 0 0 0 9 9

79

4

(Guideline)

80

(D

rug

Relat

ed P

robl

ems A

sses

smen

t Gui

delin

e: D

AG)

1. Un

treate

d in

dicati

on

()

1.1(T

he p

atien

t is in

nee

d of

drug

ther

apy b

ut is

not r

eceiv

ing it.

)

1.2

(The

new

pro

blem

has n

ot be

en id

entifi

es o

r tre

ated.)

1.3

(The

conti

nuity

of d

rug

thera

py h

as b

een

inter

rupte

d.)

1.4

(The

pati

ent is

in n

eed

of pr

ophy

laxis

or p

reme

dicati

on.)

1.5

(The

pati

ent n

eeds

a sy

nerg

istic

or p

otenti

ating

dru

g the

rapy

.)

- CD

+ R

D

- CD

+ R

D

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

2. Im

prop

er d

rug

selec

tion

()

2.1(T

he d

rug

thera

py is

ineff

ectiv

e.)

2.2

(Rec

eive

drug

ther

apy t

hat c

ontra

indica

tions

exis

t.)

2.3

(Rec

eive

a pa

rticula

r dru

g the

rapy

in th

e pr

esen

ce o

f an

aller

gy to

that

drug

.)

2.4

(The

re e

xists

an e

quall

y effe

ctive

, safe

r dru

g tha

n tha

t pre

sentl

y bein

g us

ed.)

2.5

(The

re is

an

equa

lly e

ffecti

ve b

ut les

s exp

ensiv

e dr

ug a

vaila

ble.)

2.6

(The

pati

ent is

rece

iving

comb

inatio

n the

rapy

whe

n a

single

dru

g wo

uld b

e ex

pecte

d to

be e

quall

y effe

ctive

.)

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

3. Su

b

Ther

apeu

tic d

osag

e

()

3.1 (T

he d

ose

less t

han

optim

al.)

3.2

(Rec

eive

inapp

ropr

iate

dosin

g int

erva

l.) (T

oo lo

ng)

3.3

(R

eceiv

e ina

ppro

priat

e do

sage

form

.)

3.4

(Con

versi

ons t

o dif

feren

ce fo

rmula

tion

or b

rand

.)

3.5

(Rec

eive

the e

xpire

d or

dete

riora

ted d

rugs

.)

3.6

(C

onve

rsion

s to

differ

ence

route

.)

3.7

(A

pati

ents

dos

e is

decre

ased

rapid

ly.)(W

ithdr

awal)

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ R

D

4. Ov

er

dos

age

()

4.1 (T

he d

ose

is too

muc

h.)

4.2

(Rec

eiving

inap

prop

riate

dosin

g int

erva

l.) (to

o fre

quen

cy)

4.3

(R

eceiv

e ina

ppro

priat

e do

sage

form

.)

4.4

(C

onve

rsion

s to

differ

ence

form

ulatio

n or

bra

nd.)

4.5

(C

onve

rsion

s to

differ

ence

route

.)

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

- CD

+ P

()

81

: P

= Ph

arma

cist (

)

CD

=

Cons

ult D

octor

()

RD

=

Refer

ral to

Doc

tor (

) Re

feren

ce:

1. St

rand

LM,

Mor

ley P

C, C

ipolle

RJ,

Rams

ey R

, Lam

sam

GD. D

rug-

relat

ed p

roble

ms: t

heir

struc

ture

and

functi

on. D

ICP

1990

; 24

(11)

: 109

310

97.

2. Ph

arma

ceuti

cal C

are

Netw

ork E

urop

e Fo

unda

tion.

PCNE

Clas

sifica

tion

for D

rug

relat

ed p

roble

ms V

5.01.

Zuidl

aren

: May

200

6.

5. Ad

verse

dru

g re

actio

n

()

5.1

(Side

effe

cts

Type

A A

DR)

5.2

(Dru

g all

ergy

T

ype

B AD

R)

- P

() +

CD

- P

() +

CD

6. Dr

ug in

terac

tion

()

6.1

(Dru

g

drug

inter

actio

ns)

6.2

(Dru

g

food

inter

actio

ns)

6.3

(Dru

g

disea

se in

terac

tions

)

- P

(/

) + C

D

- P

(/

) + C

D

- P

(/

) + C

D

7. Inv

alid

indica

tion

(

)

7.1

(Dru

g ab

use)

7.2

(Dru

g de

pend

ence

)

7.3

(Use

the

drug

with

out in

dicati

on)

- P (

/) +

CD

- P (

/) +

CD

- P (

/) +

CD

8. No

n

comp

lianc

e

()

8.1

8.2

8.3

8.4

(

,

)

8.5

8.6

(

/)

8.7

(/

)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

- P

(Rev

iew m

edica

tion

+ Co

unse

ling

patie

nt +

Patie

nt ed

ucati

on)

9. Di

spen

sing

erro

r

()

9.1

(Inc

orre

ct pa

tient

name

)

9.2

(Wro

ng d

rug

erro

r)

9.3

(Wro

ng d

osag

e for

m er

ror)

9.4

(Wro

ng d

rug

stren

gth e

rror)

9.5

(Wro

ng d

rug

quan

tity e

rror)

- P

() +

RD

()

- P

() +

RD

()

- P

() +

RD

()

- P

() +

RD

()

- P

() +

RD

()

82

5


83

5. (Referral Assessment: RRA)

2

1. RRA (Pharmacist Referral Assessment)

2. PRF (Physician Responded Form)

84

31 . . 2553


73

11/8 . 10310 02XXXXXXX

DM (9 ), HTN (9 ), Hyperlipidemia (9 ), Stroke (9 ) / 1) ( )

. XXXXX

MT Drug 02 539 4450

1. Amlodipine (5) 1 X 1 pc . Metformin 500 mg

2. Simvastatin (10) 1 X 1 hs . X 1 pc 9

3. Aspirin (81) 1 X 1 pc . Off ~ . . 2552 FBS

4. Omeprazole (20) 1 X 1 ac . Diabetic foot ulcer foot screening

5. . (Peripheral neuropathy), 2

6. .

7. .

8. .

9. .

10. .

11. . Medication review

12. . Consulted patient

13. . Educated patient or educated care giver

14. . Other

15.

16.

17.

18.

19.

20.

( )

/ /

/

DRP

Dosage regimen

/

.

.

1 2 3 4 5 6 7 8 9 0 1 0 1 ---- -- 5 3 5 2 1 0 0 1 0 0 0 9 9

85

31 . . 2553


73

11/8 . 10310 02XXXXXXX

DM (9 ), HTN (9 ), Hyperlipidemia (9 ), Stroke (9 ) / 1) ( )

. XXXXX

MT Drug 02 539 4450

1. Amlodipine (5) 1 X 1 pc . Metformin 500 mg

2. Simvastatin (10) 1 X 1 hs . X 1 pc 9

3. Aspirin (81) 1 X 1 pc . Off ~ . . 2552 FBS

4. Omeprazole (20) 1 X 1 ac . Diabetic foot ulcer foot screening

5. . (Peripheral neuropathy), 2

6. .

7. .

8. .

9. .

10. .

11. . Medication review

12. . Consulted patient

13. . Educated patient or educated care giver

14. . Other

15.

16.

17.

18.

19.

20.

( )

/ /

.

.

1 2 3 4 5 6 7 8 9 0 1 0 1 ---- -- 5 3 5 2 1 0 0 1 0 0 0 9 9

86

31 . . 2553

73 02 XXX - XXXX

/

F/U Compliance

F/U Clinical symptoms

F/U ADRs

F/U Drug-interactions

F/U Others

( )

/ /

(Physician Responded Form: PRF)

1 2 3 4 5 6 7 8 9 0 1 0 1 ---- -- 5 3 5 2 1 0 0 1 0 0 0 9 9

88

(Drug related problems)

2

,

1. 3 2. 1 3. 1 4. 6 1

. 3

.

:

: 1. 2.

3. 4.

5. 6.

90

.

( )

1.1

( ) , Paracetamol 1

:

:

, ,

:

: Reg. No.82/50 Reg.No.1A 301/38

( .) . 1556

/ / /

91

: , 2 , , , ,

: ,

,

? ?

60 ? ?

? ?

1.2

1.2.1 , ( ) 1.2.2 1.2.3 ,

1.2.4 2-8

, , ,

(

)

1.2.5 1 6 2 1

-

92

1.3 1.3.1

1.3.2

1.3.3 (Drug Allergy or Hypersensitivity)

1.3.4 (Side Effect)

1.3.5 (Toxic Effect)

93

1.

2.

3.

4.

5.

:

1. 2. ? ? 3.

1. 2. 3. 4.

,

, ,

94

? - /

, , ,

- ?

- ?

- - , ,

? - , , ,

? - ,

,

96

4

(Patient profile)

97

(Patient Health Profile: PHP) PHP 1:

---- / / / / :

/

1. 2. 3. : -

PHP 2:

1. ( / )

2. ( )

/ . / .

3. / / /

/ / ( )

4. / / /

5. ( ) < 10,000 10,000 30,000 30,001 50,000 > 50,000

6. ( ) < 10,000 10,000 50,000 > 50,000

- -

98

PHP 3:

( / ) ( )

( / )

( / )

( / )

( / )

/ ( / )

( )

/

( )

/ /

- -

99

PHP 4:

/

( ) PHP 5:

1. .

2. .

Chief complaint:

Visit 1:

Visit 2:

Visit 3:

/ /

- -

100

/ /

(Pha

rmac

ist M

edica

tion

Prof

ile; R

MP 1)

/

( )

/

/

.

/

/

.

/

/

.

/

/

.

/

/

.

/

/

.

/

/

.

/

/

.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

-

-

101

/ /

(Pha

rmac

ist M

edic

atio

n Pr

ofile

; RM

P 2)

/

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

-

-

102

(Pha

rmac

ist S

cree

ning

Pro

file:

RSP

1)

/ /

/

/

.

/

/

.

/

/

.

/

/

.

/

/

.

Kg

-

Cm

-

BMI

%

18

23

BP

mmHg

<

120

/ 80

HR

Bpm

70

80

FBS

mg /

dl 70

1

10

Postp

rand

ial 2

hr

mg /

dl <

200

HbA1

c %

6

7

TC

mg /

dl <

200

TG

mg /

dl <

150

LDL-

C mg

/ dl

< 10

0

HDL-

C mg

/ d

l >

40

BUN

mg /

dl 7

20

SCr

mg /

dl 0.5

1

.5

CrCl

ml

/ mi

n / 1

.73 m

2 90

1

40

Uric

acid

mg /

dl <

7

Albu

min

g / d

l 3.2

5

.0

AST

IU /

L <

35

ALT

IU /

L <

35

Alk.

Phos

. IU

/ L

35

130

Total

bilir

ubin

mg /

dl 0.1

1

.2

Dire

ct bil

irubin

mg

/ dl

0

0.3

.

:

-

-

103

(Pharmacist Screening Profile: RSP 2)

: / / .

.

.

.

.

.

.

.

. .

: / / .

.

.

.

.

.

.

.

. .

: / / .

.

.

.

.

.

.

.

. ..

- -

104


RCP1: , RCP2:

: / / .


(Actions)

(Plans)

.

- -

105


RCP1: , RCP2:

: / / .


(Actions)

(Plans)

.

- -

106


RCP1: , RCP2:

: / / .


(Actions)

(Plans)

.

- -

107

(Pat

ient

Med

icat

ion

Ques

tionn

aire

Ass

essm

ent:

PMA)

* PM

A1:

7

:

a.

//

b.

c.

d.

**

e.

/ **

f.

g.

-**

h.

-***

/

1.

2.

3.

:

1.

2.

3.

1.

2.

3.

4.

: 0.

1.

2.

3.

4.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

/ /

.

-

-

108 PM

A2:

:

a. /

()

b. /

c.

d.

e.

()

f. (

)

g.

h. (

)

i.

()

j.

k.

l.

(

) m.

......

......

......

......

......

......

......

......

......

......

......

......

......

......

n. ...

......

......

......

......

......

......

......

......

......

......

......

......

......

...

o. ...

......

......

......

......

......

......

......

......

......

......

......

......

......

...

p. ...

......

......

......

......

......

......

......

......

......

......

......

......

......

...

-

-

109

PMA3: (Adherence Rick Assessment)*

:

1 =

0 =

3. Regimen non-adherence ( a e PMA1 ) 1.8

(Patient Medication Profile : PMP) 1a

1.9 1b 1.10 / 1c,1d 1.11 / 7 1e 1.12 1b,1c,1d 1.13 1 1a,1b,1c,1d,1e 1.14 1 1a, 1b,1c,1d,1e

Regimen non-adherence (Score of 1 indicates Positive screen for Regimen non adherence)

4. Negative beliefs or motivational barriers ( g h PMA1 ) 2.3 1g 2.4 1h

Negative beliefs or motivational barriers (Score of 1 indicates Positive screen for Negative beliefs or motivational barriers)

4. Recall Barriers ( c PMA1 h PMA2 )

3.3 1 2 1c 3.4 2h

Recall Barriers (Score of 1 indicates Positive screen for Recall barriers)

5. Access Barriers ( j l PMA2 ) 4.4 2j 4.5 2k 4.6 2l

Access Barriers (Score of 1 indicates Positive screen for Access barriers)

*Adapted from: Svarstad et al (1998) Total scores

. / /

110

(Patient Knowledge Assessment: PKA) PKA1:

1. 1.1

1.2

1.3

2. 2.1

2.2 ( )

2.3

3. 3.1

4.

4.1

4.2

4.3

4.4

4.5

6. ( ) 6.1 ( )

6.2

6.3

PKA2:

1. 2. 3. 4. 5. 6.

/ /

- -

112

72 14 10230 0 2940 3813 , 0 2940 3981 16E-mail : [email protected]

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