1. 出院衛教準備服務
日 期: (日) 13:00-13:30
報告者: 吳秉峰 藥師
中國醫藥大學附設醫院藥劑部

2. Outline A Pharmacist’s Role Pharmaceutical Care S O A P
Patient Assessment
Patient Education
Case Report

3. A Pharmacist’s Role

4. Pharmacist’s Role Today
In the past: Take Rx order, dispensing, distributing, patient counselling.
Today, the role of pharmacists is becoming increasingly patient-oriented. Therefore, is not uncommon for patients to have pharmacists solely providing patient assessment.

5. Future Pharmacist’s Role
Future: provide some level of primary care
Administer Vaccinations.
Order lab tests.
Engage in disease management activities, including make diagnoses of certain clinical conditions.
Change dosage of Rx, change Rx order, prescribing.
Dispensing OTC products.

6. The evolving role of the pharmacist
Move from counting & dispensing medications, more toward focus on treatment & knowledge of the product.
More patient interaction and patient counselling.
Play key role in patient safety.
A greater involvement in assisting patients with managing their disease states.
A greater information source for the patient.

7. College of King

8. Pharmaceutical Care

9. Pharmaceutical Care
Definition: the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life. (Hepler CD, Strand LM.1990)
Cure of disease.
Elimination or reduction of a patient’s symptom.
Arresting or slowing of a disease process.
Preventing a disease or symptom.

14. Sequence and Components for Presenting Information
Gen: General Patient Information.
CC: Chief Complaint.
HPI: History of Present Illness.
PMH: Past Medical History.
FH: Family History.
SH: Social History.
Allergy History.
MedHx: Medication History (Prescription and OTC ).
ROS: Review of System.

15. Sequence and Components for Presenting Information
PE: Physical Exam
Lab: Laboratory and diagnostic test results
Admission Diagnosis
Hospital Course
Complication
Discharge Diagnosis
Recommendations & Medications
S O A P

16. Cambridge

17. S O A P

18. S O A P S： CC HPI PMH FH SH Allergy MedHx ROS P： Recommendations &
Medications
CC: Chief Complaint.
HPI: History of Present Illness.
PMH: Past Medical History.
FH: Family History.
SH: Social History.
MedHx: Medication History.
ROS: Review of System.
PE：Physical Exam
Lab：Laboratory and diagnostic test results O： PE
Labs
Operation A：
Admission Diagnosis
Hospital Course
Complication
Discharge Diagnosis
Drugs List

19. Patient Assessment

20. What needs to be considered
Patient information.
Disease information.
Drug information.

21. Disease Assessment Problem Identification. Signs and Symptoms.
Treatment Goal.
Desired Outcome.
Supportive Data.
Therapeutic Alternatives.
Optimal Plan.
Outcome Evaluation.

22. Drug Assessment Drug use without indication. Untreated indication.
Improper drug selection.
Subtherapeutic dosage.
Overdosage.
ADR.
Drug interaction.
Failure to receive medication.

23. Problem List List of drug’s problems.
Use Evidence-based information to assist healthcare team to identify the problem(s).

24. Plan Action Plan for treating this patient. Including interventions.
Patient education.
Follow-up plan.
Follow-up evaluation.

25. College of Queen

26. Patient Education

27. Name of Drug
Administration, dosage, frequency, duration of usage
Special instruction.
Storage.
Self-monitoring.
Chronic usage, refill information.
Contraindication, caution.
ADR, side effect.
Drug-Drug, Drug-Disease, Drug-Food interaction.
What to do if you forget one dose.

28. Case Report

29. General information(Gen)s
General information(Gen)
姓名: 鄭XX
病歷號:
00147XXXX5
住院期間:
96/11/22~96/11/28
年齡: 78歲
身高: 157cm
性別: 女
職業: 家庭主婦
體重: 64kg
過敏史: NKDA

30. s Chief Complaint (CC): History of Present Illness (HPI) :
--chest tightness and general weakness for 2 week.
History of Present Illness (HPI) :
--78 y/o female with history of HTN, heart disease, hyperuricemia, CKD suffered from chest tightness and general weakness for 2 week, intermittent chest pain, no radiation pain, no cold sweating, no dyspnea, orthopnea(-), no leg edema, heart burn(+), hoarseness(+), few cough for 2 days-> r/o GERD,no stool passage for 3 days, no abdominal pain.

31. Past Medical History s 過去六個月就診錄: 日期 科別 診斷 96/10/16 腎臟科 背痛、慢性腎衰竭、痛風
96/10/23
腎臟內科
背痛、慢性腎衰竭、痛風、自發性高血壓
96/11/20
心臟科
自發性高血壓、焦慮狀態、痛風、高尿酸血症、失眠、眩暈
96/11/22
急診內科
眩暈、自發性高血壓

32. Physical Examination O General appearance: --acute illness, nourished.
Mental state:
--alert and well-orientated.
Vital sign:
--T/P/R: 36.2 / 70 / 18, BP: 135 / 67 mmHg
Perfusion and oxygenation:
--warm extremities without cyanosis.
HEENT:
-- gross normal; pink conjunctiva, anicteric sclera.
Anicteric 無黃疸的

33. Physical Examination O Neck:
--supple; no palpable lymphadenopathy or thyroid nodules.
Chest:
--symmetric expansion; Breath sound: clear.
Heart:
--regular heart beats with systolic murmur.
Abdomen:
--no tenderness or muscle guarding, normoactive bowel sounds.
Extremities:
--free movable, but muscle weakness.
Lymphadenopathy

34. Laboratory and diagnostic test results

35. Lab.Data
Unit
normal
10/16
10/23
11/22
SGPT
(ALT)
IU/L
0-40 69
SGOT
(AST)
5-34 61
CPK 女:
26-140
887
B.U.N
mg/dl
5-26 33 21
Creatinine
1.6
1.5
Uric acid
13.5
10.1
CCR
ml/min
88-128
45.9
Phosphorus
5.0
MCH pg
27-31
31.2

36. T1-201 STRESS / REST MYOCARDIAL PERFUSION SPECT
Lab.Data
Unit
normal
10/16
10/23
11/22
Monocytes %
3.4-9
18.1
Nitrite
Negative +
Leukocyte
Epith. Cell
1/HPF
0~5
8/HPF
WBC 8
Triglyceride
Mg/dl
35-165
214
96 / 10 / 16
Renal Sonography:
--Bilateral small kidneys, C/W chronic renal disease, bilateral renal cysts.
96 / 11 / 20
T1-201 STRESS / REST MYOCARDIAL PERFUSION SPECT
--suggesting stress-induced myocardial ischemia, suggesting stress-induced LV dysfunction.

37. Admission Diagnosis A Chest pain, suspect GERD, CAD. HCVD.
CKD, stage III.
Gout.
Constipation.
Insomnia.
GERD: Gastroesophageal Reflux Disease.
CAD: Coronary Artery Disease.
HCVD: Hypertension Heart Disease
CKD: Chronic Kidney Disease.

38. A
Hospital Course
Due to EKG in ER showed normal, and no increase in troponin I lever, ACS was no likely.
After admission, she was arranged PES which showed gastric ulcer, GERD and CLO(+).
Triple therapy was prescribed.
Medicine as CV OPD, laxative agents, sedative agents, and analgesic agents were prescribed too.
EKG: electrocardiograph
ACS: Acute Coronary Syndroms
PES: Pendoscope
CLO(+): Endoscopic biopsy for rapid urase assay.

39. A
Drugs List

40. Acetaminophen 500 mg/T (1TB) QID.PO STAT STAT
Item / Dose
Frequency
11/22
(住院)
11/23
11/24
11/26
11/27
11/28
(出院)
Allopurinol 100 mg/T (1TB)
QD.PO 
Colchicine 0.5 mg/T (1TB)
MELOXICAM 15 mg/Tab (1TB)
STAT 
Acetaminophen 500 mg/T (1TB)
QID.PO
STAT
STAT
Aspirin 100 mg/Cap (1Cap)
Valsartan 80mg/T (0.5TB)
Amlodipine Besylate 5 mg/T (1TB)
Diltiazem 30 mg/Tab (1TB)
STAT.TID.PO
Nicorandil 20 mg/Tab (1TB)
BID.PO
Isosorbide Dinitrate 10 mg/T (1TB)
Bisoprolol 5 mg/T (0.5TB)
Nicametate Citrate 50 mg/T (1TB)
TID.PO
Flunitrazepam 2 mg/T (1TB)
HS.PO
Zopiclone 7.5 mg/Tab (1TB)
Diphenidil 25mg/Tab (1TB)
STAT.P

41. Clonazepam 0.5 mg/Tab (1TB) TID.PO STAT  Imipramine 10 mg/T (1TB)
HS.PO 
Sato syprup 120 mg/BT (複方)
(適量1BT)
Omeprazole Infusion 40 mg/VI (1VI)
Q12H.IVD
Amoxicillin 250 mg/Cap (4Cap)
BID.PO
Clarithromycin 250 mg/T (2TB)
Rabeprazole 20mg/Tab (1TB)
QD.PO
Meperidine 50 mg/ml/Amp (1 Amp)
STAT.IVD
Castor oil 30 mg/BT ( 20 )
STAT.PO
STAT
Bisacodyl (栓劑) 10 mg/supp.
(2 supp.)
STAT.
RECT
Bisacodyl 5 mg/T (2TB)
Meclizine HCl 25 mg/Tab (1TB)
Butylscoplamine 20 mg/cc/Amp
(1 Amp)
Mucaine Tab (複方) (1Tab)
Posterisan Forte Oint. 10gm/Tube (適量1TU)
QD.EXT

42. Discharge Diagnosis A Chronic ischemic heart disease.
Hypertensive heart disease.
Gastric ulcer.
Gout arthritis.
Chronic renal insufficiency.
Dizziness and giddiness.
Degenerative joint disease.

43. Recommendations＆MedicationsP
Recommendations＆Medications
Item
Dose
Frequency
Dosage
Amlodipine Besylate 5 mg/T
1TB QD PO
Bisoprolol 5 mg/T
0.5TB
Valsartan 80mg/T
Rabeprazole 20mg/Tab
Amoxicillin 250 mg/Cap
4Cap
BID
Clarithromycin 250 mg/T
2TB
Bisacodyl 5 mg/T
Flunitrazepam 2 mg/T HS

44. A & P
Problem List

45. Problem 1 A & P Amlodipine Besylate 5 mg/T 1TB QD PO Bisoprolol 5 mg/T
Item
Dose
Frequency
Dosage
Amlodipine Besylate 5 mg/T
1TB QD PO
Bisoprolol 5 mg/T
0.5TB
Valsartan 80mg/T
Rabeprazole 20mg/Tab
Amoxicillin 250 mg/Cap
4Cap
BID
Clarithromycin 250 mg/T
2TB
Bisacodyl 5 mg/T
Flunitrazepam 2 mg/T HS
Amlodipine Besylate, Bisoprolol, Valsartan適合用在治療患有Chronic ischemic heart disease及Hypertensive heart disease的年老患者身上嗎?
Chronic renal insufficiency患者服用此三類藥應當如何劑量?

46. A & P The elderly hypertensive patient (>60 years) :
--CCB (Amlodipine Besylate) decrease vascular resistance, have no adverse effects in lipid levels, are good choices for elderly.
--Even though elderly patients tend to have low plasma renin activity, ACEI and ARB (Valsartan) may be effective agents in this population.
--Long-term studies have documented the safety and efficacy of BB (Bisoprolol), especially after acute MI.
The hypertensive patient with coronary artery disease:
--is at increased risk for unstable angina and MI, BB (Bisoprolol) may be used as first-line agents in these patients.
The Washington Manual of Medical Therapeutics, 29th Edition

47. A & P Amlodipine Besylate --Dosage Oral:
Hypertension: initial, 5 mg once daily; maintenance 5-10 mg once daily.
Elderly, fragile, or small: for hypertension, or when adding to other
antihypertensive therapy starting dose 2.5 mg once daily.
Bisoprolol:
-- Dosage Oral:
Hypertension (JNC 7): mg once daily.
Elderly: initial,2.5 mg/day, may be increased by mg/day;
maximum recommended dose, 20 mg/day.
ClCr < 40 mL/min: Initial: 2.5mg/day.
Valsartan:
Hypertension: Initial: mg once daily ( In patients who are
not volume depleted ); maximum recommended dose: 320 mg/day.
The Washington Manual of Medical Therapeutics, 29th Edition
Drug Information Handbook, 13th Edition.
Drug Facts and Comparisons, 2006.

48. Amlodipine Besylate 5 mg/T
A & P
Problem 2
Item
Dose
Frequency
Dosage
Amlodipine Besylate 5 mg/T
1TB QD PO
Bisoprolol 5 mg/T
0.5TB
Valsartan 80mg/T
Rabeprazole 20mg/Tab
Amoxicillin 250 mg/Cap
4Cap
BID
Clarithromycin 250 mg/T
2TB
Bisacodyl 5 mg/T
Flunitrazepam 2 mg/T HS
Rabeprazole, Amoxicillin, Clarithromycin, 適合用在Gastric ulcer的患者上嗎?
Chronic renal insufficiency患者服用此三類藥應當如何劑量?

49. A & P Reflux esophagitis:
--symptomatology includes heartburn, dysphagia, chest pain, and variety of ear, nose, and throat symptoms (hoarseness, sore throat). The lower esophageal sphincter (LES, e.g., theophylline, CCBs, BB, nitrate, anticholinergics.) is the major barrier against reflux.
Rabeprazole:
--short-term (4-8 weeks) treatment and maintenance of erosive or ulcerative GERD with Helicobater pylori infection.
Dosage Oral: Adults > 18 years and elderly:
GERD: 20 mg once daily for 4-8 weeks; maintenance: 20 mg once daily.
H. pylori eradication: 20 mg twice daily for 7 days; to be administered with amoxicillin 1000 mg and clarithromycin 500 mg, also given twice daily for 7 days. All 3 medications should be taken twice daily with the morning and evening meals.
The Washington Manual of Medical Therapeutics, 29th Edition
Drug Information Handbook, 13th Edition.
Drug Facts and Comparisons, 2006.

50. Amlodipine Besylate 5 mg/T
A & P
Item
Dose
Frequency
Dosage
Amlodipine Besylate 5 mg/T
1TB QD PO
Bisoprolol 5 mg/T
0.5TB
Valsartan 80mg/T
Rabeprazole 20mg/Tab
Amoxicillin 250 mg/Cap
4Cap
BID
Clarithromycin 250 mg/T
2TB
Bisacodyl 5 mg/T
Flunitrazepam 2 mg/T HS

51. Punting

52. A & P
Plan

53. 3.藥師先評估用藥合理性，必要時請醫師修改適合之藥物
中國醫藥大學附設醫院作業標準書
1.病人預出院前，出院準備小組護理師開出臨床藥學科用藥指導會診單
6.查詢病人電子病歷並記載所需資料
2.經由負責藥師確認後，有足
夠時間至病床邊提供用藥指導
7.指導病人或照顧者用藥注意事項
3.藥師先評估用藥合理性，必要時請醫師修改適合之藥物
8.請被指導者回覆示教
4.與主護護士連繫，確認用藥指導之時間及指導對象
5.依約定時間至病房

54. 中國醫藥大學附設醫院預出院病患用藥衛教記錄表
床 號：
性別：男 女
年 齡：
出院日期：
主治醫師：
姓 名：
體重： kg
職 業：
衛教日期：
藥師：
病歷號：
身高： cm
住院日期：
花費時間：衛教時間：
準備時間：
覆述結果：
1.優 4.不佳
2.良好 5.沒反應
3.尚可
住院診斷：如醫囑單
其他
NIL
電話：
使用藥物：如醫囑單所列藥物內容
補充說明：
提供用藥指導單張
過敏紀錄：
NKA
指導對象： 本人 家屬
看護 外傭 朋友
衛教內容：
適應症、作用 用法 用量
服藥時間 注意事項
保存方式
特別指導

55. Total: 374

57. 衛教科別 一般內科 16 骨科 3 急重症外科 6 心臟科 12 腎臟科 17 神經外科 50 心臟血管外科 1 感染科 胸腔科 46
耳鼻喉科
新陳代謝科 2
肝膽腸胃科
血液腫瘤科
直腸外科
免疫風濕科
數據收集自96.10~97.03
Total: 159

58. Total: 159
136 12 9 2 不佳 尚可 良好 優良
數據收集自

59. 中國醫藥大學附設醫院出院病患床邊用藥衛教電聯追蹤評估表
姓 名：
性別：男 女
年 齡：
住院期間：
主治醫師：
病歷號：
體重： kg
職 業：
語 言：
藥師：
科 別：
身高： cm
教育程度：
衛教日期：
花費時間：
電聯追蹤回覆結果：
 1.優
 2.良好
 3.尚可
 4.不佳
 5.沒反應
提醒病患內容包括：藥物適應症、用法、用量、服藥時間、注意事項、保存方式及是否服用保健食品或其他藥品等。
用藥遵醫囑性：
 good
 doubtful（含糊、不明確的）
 poor
主要問題：
 忘記
 不瞭解
 故意不遵從用藥醫囑性
補充說明：
電聯追蹤對象：
本人 家屬（請註明： ）
外傭 看護 朋友
藥師於床邊用藥衛教滿意度：
1.非常滿意 2.滿意 3.普通
4.不滿意 5.非常不滿意
使用藥物品項： 種
註解定義: 1.優：表示現用藥物內容全部答對; 2.良好：表示現用藥物內容超過三分之二以上答對; 3.尚可：表示現用藥物內容答對一半; 4.不佳：表示現用藥物內容只答對三分之ㄧ以下; 5.沒反應

60. Total: 48 42 4 2 普通 滿意
非常滿意
不滿意
數據收集自

62. ～　謝謝聆聽　～

63. Patient-oriented: For or interested in a particular type of person or thing.
Patient assessment: The critical analysis and evaluation or judgement of the status or quality of particular condition, situation or other subject of appraisal.
Patient safety:對於健康照護過程中引起的不良結果或損害所採取的避免、預防與改善措施。

64. 評分標準