F329 – Documentation Templates Related to Key Steps in the Care Process
Key Steps
Key Questions
Physician Roles
Documentation examples
RECOGNITION
Define patient
problems and
risks
- What are the
individual=s
symptoms, needs,
abilities, deficits,
risks, comorbid
conditions,
prognosis, etc?
- What do the
patient’s symptoms
mean, and are they
significant?
- History and physical exam findings that support the
conclusion that medication is needed (indication),
selection of a particular medication or a particular
dose of that medication
- Components of history and physical exam that
define the problem, identify the cause, and justify the
need for a medication
- A clear problem statement that indicates why a
medication is indicated
- Test results that clarify the nature, significance, and
causes of symptoms and risks
- Other relevant information (observations and data)
from other disciplines about the patient=s physical,
functional, and psychosocial status, symptoms, needs,
abilities, deficits, risks, comorbid condition,
prognosis, etc.
- Rhythm strip shows frequent AF, patient is at risk
for stroke and cannot tolerate anticoagulant;
therefore, antiarrhyhmic is indicated; will monitor
closely for medication effectiveness and
complications
- Physical exam revealed specific area of muscle
tightness and pain to palpation, most likely spasms
- Patient had warm, tender, swollen joint consistent
with exacerbation of chronic arthritis
- Exam showed that patient had delusions and
paranoia, consistent with recurrence of psychosis
- Patient explained that family issues made her
become agitated and upset; not a new situation; no
reason to give a medication for these normal
reactions to personal problems
- Incontinence classified as urge based on patient
symptoms; could benefit from trial of medication,
but her dementia may make her be susceptible to
anticholinergic effects
DIAGNOSIS /
CAUSE
IDENTIFICATION
Clarify symptoms
and identify
- What factors are
causing or affecting
signs, symptoms,
and risks?
- Information that helps identify factors (acute or
chronic medical conditions, medications, etc.) that are
most likely causing or contributing to symptoms or
risks
- Relevance of tests and interventions to overall
condition, prognosis, wishes, risks, etc.
- Heart failure is causing elevated BUN/creatinine
ratio because of decreased blood flow to the
kidneys; therefore, diuretics are indicated
- Patient receiving antiepileptics for supposed
neuropathic pain, but the symptoms persist and have
been very nonspecific; will taper medication and try
Key Steps
causes
Key Questions
Physician Roles
TREATMENT
Determine
whether a
medical
intervention is
indicated
- When should a
symptom,
condition, or risk
factor be addressed
with a medical
intervention, and
when should that
medical
intervention
include
medications?
- Collaborate with those of other disciplines to
identify situations where alternatives to medications
may be appropriate, and help staff select relevant
alternatives
- Determine whether the patient could benefit from a
medical intervention, based on relevant considerations
(e.g., prognosis, wishes, ability to cooperate with
treatment, potential benefits and risks posed by
treatment, relevant clinical literature, etc.)
- Based on weighing relevant information, determine
that a medication is appropriate
Make initial
medication
selections
- When a
medication is
indicated, which
- Prescribe medication in doses and for a duration that
are pertinent to a patient=s overall situation (including
the patient=s existing medication regimen, risk
Documentation examples
acetaminophen
- Worsening constipation may be due to several
medications with high anticholinergic properties;
will lower doses of those medications and check
status
- Patient has asymptomatic bacteriuria, for which he
was receiving antibiotics in the hospital, which
probably led to antibiotic-induced diarrhea; should
not be treated with antibiotics unless clearly
symptomatic.
- Patient was placed on cholinesterase inhibitor in
the hospital d/t diagnosis of dementia, but it is
alcohol-related dementia, which is not an indication.
- Patient has had change in mood recently, but it is
related to an identifiable situation, and is not
associated with significant functional impairments;
medication is not needed at present.
- Patient pushed another resident, but staff identified
that the other individual had tried to take her
belongings. This patient’s behavior does not reflect
a medical condition that would warrant a
medication intervention.
- Patient was placed on a muscle relaxant by a
covering physician; the symptoms have subsided;
there is no clear underlying cause. Will D/C muscle
relaxant because of associated sedation, and order
local ice and heat plus acetaminophen, as needed.
- Patient is already receiving several
antihypertensive medications and other medications
that can affect blood pressure.
Key Steps
Authorize
medications
appropriately
Key Questions
medication, dose
and duration are
appropriate?
Physician Roles
factors, comorbidities, potential medication benefits
and adverse consequences; physical, functional, and
psychosocial status; symptoms, needs, abilities,
deficits, risks, wishes, prognosis, etc.) and that take
into account potential benefits and risks of proposed
medications
- Strive to minimize situations where a patient
receives high risk medications and dosages without
clear clinical justification, consideration of safer
alternatives, or intensified monitoring
Documentation examples
- Given this patient’s underlying condition and
prognosis, she is unlikely to benefit from
cholesterol-lowering medications.
- Because this patient is active and mobile, and has
a life expectancy of at least several years, a
bisphosphonate is indicated in addition to calcium
and Vitamin D, to try to improve bone density.
- This patient prefers to be allowed to eat what he
wants; previous attempts at tight blood sugar control
have resulted in hypoglycemic episodes; therefore,
it is not likely to be helpful to increase the number
or doses of current oral antidiabetic medications or
to switch to insulin.
- This woman has a significant risk for falling and
fracturing a hip; in addition, she is 87, and the
evidence is that excessive BP reduction at that age
may be more harmful than helpful; therefore, we
will try using the lowest possible doses of
medication and keep the target BP around 145/80.
- How should
orders be written to
ensure that they are
appropriate, timely,
safe, and compliant
with pertinent legal
and regulatory
requirements?
- How will the
prescribed
- Write or give orders that are appropriate, timely,
safe, and compliant with pertinent legal and
regulatory requirements
- Identify the goals of therapy and parameters for
monitoring the medication’s efficacy and safety
- Ensure that any Aas needed (PRN)@ orders contain
key information including the indication(s), specific
circumstance(s) for use, and the desired frequency of
administration.
- Synthroid 0.15 mg, not Synthroid 150 mcg.
- Lasix 40 mg qday or daily, not q.d.
- Hydrochlorothiazide, not HCTZ
- The goal of treatment for this patient is to reduce
pain to a level where she can perform her ADLs,
while trying to avoid side effects that affect her
cognition and appetite.
- The patient has been afebrile and asymptomatic
for 48 hours; therefore, we can stop the antibiotics
after 6 days, to try to minimize the risk of
Key Steps
MONITORING
Assess the
patient=s
progress,
including the
impact (both
positive and
negative) of any
interventions
Decide whether
to modify the
existing
medication
regimen
Key Questions
medication be
evaluated for safety
and efficacy?
- What is to be
assessed in order to
determine the
effectiveness of
medications and
identify related
adverse
consequences?
- Which of a
patient’s existing
medications should
be continued, and
which should be
modified or
discontinued?
- Is the patient
experiencing any
adverse
consequences, and
what is their
significance?
Physician Roles
- Review the patient’s progress, discuss with other
staff and re-examine the patient, as indicated, to
ascertain current status
- Establish or confirm goals for treatment and
monitoring parameters, including for specific
medications or combinations
- Evaluate benefits and possible adverse consequences
of the existing medication regimen
- Be alert to the possibility of adverse consequences in
any patient with new onset significant symptoms,
condition change, functional decline, failure to
improve as anticipated, or otherwise unexplained
findings
- Respond promptly and act appropriately after
identifying, or when informed of, suspected adverse
consequences related to one or more current
medications
- Determine the clinical significant of any adverse
consequences including their impact on the patient’s
medical and psychological condition, function, and
quality of life
Documentation examples
gastrointestinal complications.
- The patient remains incontinent of urine, so there
does not appear to be any benefit from using an
anticholinergic medication.
- Acute pain is less frequent and severe, so it is
appropriate to try tapering the analgesics to see if
comfort can be maintained with lower doses or less
frequent use.
- The goal for this patient is fewer exacerbations of
socially inappropriate behavior due to her chronic
anxiety disorder; it is unlikely that these can be
eliminated with medications
- Because the patient is on both a diuretic and an
ACE inhibitor, and is at risk for hydration issues,
BMP monitoring is indicated if there is a significant
change of condition such as decline in function or
increased lethargy.
- Patient was placed on an antidepressant
approximate 8 weeks ago, with no significant
change in function or mood despite dose increases,
according to nursing staff. Therefore, it is
appropriate to reconsider the working diagnosis and
whether this medication is indicated, before
increasing the dose or adding any more medication.
Is Your Doctor in Denial?
Survey Finds Physicians Often Dismiss Complaints About Drugs' Side Effects
http://www.washingtonpost.com/wp-dyn/content/article/2007/08/24/AR2007082401714.html
By Ishani Ganguli
Special to The Washington Post
Tuesday, August 28, 2007; HE04
On many online message boards and Internet chat rooms, anxious patients share details about the
muscle pain and memory loss they have noticed since they started taking statins to lower their
cholesterol. A new study suggests these people may be seeking validation for good reason: Some
of their complaints might otherwise be going unheard.
According to a survey of 650 patients published last week in Drug Safety, a peer-reviewed
journal, doctors frequently ignored or dismissed patients' concerns about such side effects. The
study suggests this pattern of reaction goes beyond statins to other drugs.
When doctors fail to recognize a patient's symptoms as drug side effects, more than that patient's
care is put at risk. Because the doctor makes no "adverse event report" to the Food and Drug
Administration, the regulatory agency may underestimate the problem, and other doctors and
patients may assume the drug is safer than it is.
Researchers from the University of California at San Diego had been investigating the side
effects of statins when they noticed the problem.
"Person after person spontaneously [told] us that their doctors told them that symptoms like
muscle pain couldn't have come from the drug. We were surprised at how prevalent that
experience was," said Beatrice Golomb, associate professor of medicine and the study's lead
researcher.
Tens of millions of people worldwide take statins such as Lipitor and Zocor. Many experts view
them as something of a panacea for everything from stroke and cancer to arthritis, although they
do pose a risk of side effects in some patients, ranging from muscle injury to liver and kidney
dysfunction.
Survey respondents, recruited via Web solicitations and other advertisements, were in their early
60s on average and mostly from the United States. Some of the solicitations were placed on Web
sites where patients had posted complaints, raising the possibility that respondents were more apt
to have had side effects than the average patient. Most said they'd complained to their doctors
about such possible side effects as problems with memory or attention, or tingling or numbness
in their hands and feet.
According to experts, muscle pain and other side effects occur in up to 30 percent of statin
patients, by some estimates, and often lead doctors to stop or change a prescription. But patients
surveyed said their doctors rarely linked their symptoms to statins -- even when the symptoms
were well-documented as side effects.
"Overwhelmingly, it was the patient that initiated that conversation" making the connection
between the statin and their symptoms, Golomb said.
Many doctors instead attributed the symptoms to the normal aging process, denied their
connection to statins or dismissed the symptoms altogether -- missing opportunities to switch
their patients' prescriptions or otherwise mitigate the side effects, Golomb said.
Golomb speculated that doctors' actions might reflect the relative dearth of information on the
downsides of statins. "Ad campaigns that preserve statins' miracle drug image are more powerful
than education about side effects," she said.
The findings raise important concerns about American drug safety monitoring, said Harvard
Medical School professor Jerry Avorn, author of "Powerful Medicines: The Benefits, Risks and
Costs of Prescription Drugs."
"We already know that there is horrendous underreporting of side effects. Ninety to 99 percent of
serious side effects are not reported by doctors," he said.
Yet the FDA relies heavily on their reports. Tracking a drug's safety once it hits pharmacies -so-called post-market surveillance -- is a critical part of keeping patients safe, particularly since
clinical trials with limited enrollees and a limited study period cannot catch every side effect.
Managed care deserves some of the blame, Avorn said. "Part of [the problem] is that doctors are
granted so few minutes to deal with patient visits. It's not as if doctors don't care."
Golomb and others worry that if even well-documented side effects aren't being recognized by
doctors, others will take much longer to surface. "A fifth of all drugs that fully pass FDA
approval will ultimately have black box warnings or be withdrawn from market because of
adverse effects," Golomb said.
Some say that the FDA and drug companies should work harder to get feedback directly from
patients. Getting drug surveillance reports from patients is common practice in New Zealand and
other countries.
U.S. patients can report side effects to the FDA themselves -- by logging onto the MedWatch
Web site ( http://www.fda.gov/medwatch). But few know about this option, Avorn said.
The new study "points out that doctor reports on side effects is a very unreliable means of
learning about the true extent of problems," he said. "We ought to have a [better] mechanism for
gathering information from patients. A lot of it will be noise, but there may be important signals
there as well."