1. 藥事執業技能：藥物相關問題之解決 Pharmacy Practice Skills: Drug-Related Problems Solving

2. 課程目的 了解 systematic clinical drug monitoring 的重要性與目的
說明 SOAPing format 之組成及擷取藥事服務所需資訊
了解 patient case presentation 之結構及順序
學習以 SOAPing format 建立完整的合理用藥評估
藉案例學習，引導學生與指導老師充分互動
-重視討論的過程，而非結果

3. Systematic Clinical Drug Monitoring的重要性
The responsibility of a pharmacist to provide services in a consistent and complete manner
The complexity of a patient’s health problems
The comprehensible communication among health care professionals

4. The Purposes of Systematic Clinical Drug Monitoring
Determine that all of a patient’s drug therapy is the most appropriate, most effective, safest, and most convenient available.
Identify any drug therapy problems (DTPs; DRPs) and the goal of therapy.
Identify any drug therapy problems (DTPs) the patient is at risk of developing in the future that is to say, any drug therapy problems the pharmacist must help the patient to prevent in the future

5. Pharmaceutical Care Process

6. Problem-Oriented Approach
In 1964, Lawrence E Weed published the problem-oriented approach to medical records, patient care, and medical education.
A systematic, disciplined approach to each patient is used
No important therapeutic considerations are missed

7. Problem-Oriented Approach
Two main components
Complete problem list
Physical
Psychological
Social/financial
SOAP notes
Logical thinking process
連結理論和臨床, 並應用在醫療照顧
One visit one SOAP

8. POMR Problem Oriented Medical Record
Dr. Lawrence Weed 提出將病歷制式化的構想
POMR= Problem List (第 x 項) + 各個 SOAP
Problem 1+ SOAP 1
Problem 2+ SOAP 2
… …
Modified SOAP S O
A (Problem 1, 2, …)
P (Problem 1, 2, …)

9. 教學大綱 課程目標 病歷之基本組成 From database to plan SOAPing format
Patient Case Presentation
From database to plan
1. From data base to assessment (SOAP notes)
2. Assessment
3. From assessment to plan (Implentation)
SOAPing format
案例說明
Daily SOAP note
Oral case presentation

10. 教學內容重點

11. 實際指導學生實習-案例討論 課程準備 安排課程表-學習過程
準備內容教材(挑選主題, 範例, 實例, workbook, pharmacotherapy之參考依據)
Disease Management Case Demo (ASHP’s PharmPrep 2001)
Terry L. Schwinghammer pharmacotherapy Casebook 6th Ed.
課程分配
需多堂課 (10幾個小時)
漸進地介紹,才能完成
1. 上課解說 2小時
2. 範例說明 1小時
3. 學生實例演練 SOAPing format及討論
(2小時/次, 共 5-6次)

12. 病歷之基本組成

13. 病歷之基本組成 首頁
門診病歷
住院病歷
急診病歷

14. 住院病歷 病歷摘要 (Discharge summary) 醫囑單 (一般 / 特殊 -TPN 及 C/T) TPR sheet
Admission note (內科及外科 / 一般或各專科病歷用紙)
Progress note (SOAP format)
會診記錄
治療申請單 (X-ray, Cath, RT)
檢驗報告 (Lab data)
監測觀察記錄單 (GCS, APACHE II scale)
輸入輸出記錄表 / 膀胱訓練記錄表
手術記錄
給藥記錄
護理評估表/ 護理記錄
出院準備服務 個案篩選表 / 收案病患記錄表

15. Medication Administration Record (MAR)
Routine or maitenance
Antibiotics, anticonvulsants
P.R.N.
Usually are listed at the end of the MAR
Fever (if >38.5℃)
Pain medication
Antiemetics
Sedative-hypnotic agents
Stat (Statim, immediately)
Administered once and not repeated unless recorded
Given as soon as possible
Prescribed in life-threatening or emergency situations
One time order
Given as soon as convenient and sometimes can be scheduled ahead of time
C/T

16. 住院日誌 Progress Note 目的 提醒每天病人發生了什麼事以及醫師目前的想法
精神-忠實記錄, 簡短(縮寫), 清晰易讀, 遵守常用習慣
重要性
對病患病程的演進，客觀的變化，醫師的判斷，臨床的因應做一個重要的記錄
對病患而言，這是他的”傳記”，是他一生最重要的記錄
對醫師而言，這是他訓練過程的”事證”，對自己的想法與做法留下記錄;也是醫師間溝通的工具
對醫療而言，是醫療的重點記錄，是疾病處理的基本依據，是繼續醫療的重要參考
對醫學而言，是人類醫學的重要資產，是醫學進步重要文獻
格式-SOAP format

17. 常用縮寫
一般身體評估(身體診察)
疾病診斷
藥品及其用法
檢查名稱

18. 推薦讀物 (入門) 醫護專用縮寫辭典 (杜武志 主編) 取材範圍廣泛 台大內科住院醫師醫療手冊 (楊汾池 總編)
醫, 牙, 藥, 護, 檢驗, 管理
疾病診斷, 理學檢查, 名稱, 病歷用語
台大內科住院醫師醫療手冊 (楊汾池 總編)
一般內科訓練 (primary care training)
綜論 (醫療實務要點, 各病房特殊檢查及術後照顧)
各論 (CV, GI, Nephro, Chest, Endo, Neuro, Rheuma,
ID, Hema, Oncology)
The Washington Manual of Medical Therapeutics 31ed.
Clinical skills for pharmacists, A patient-focused approach. 2nd Ed. Karen J. Tietze, Mosby

19. Patient Case Presentation
The accepted tool for documenting and communicating patient information (suggested by Tietze, K.J.)

20. Components of the Patient Case Presentation
General information
Chief complaint (CC)
History of present illness (HPI)
Past medical history (PMH)
Medication history (MedHx)
Family history (FH)
Social history (SH)
Review of systems (ROS)
Physical examination (PE)
Pertinent positive and negative laboratory and diagnostic test results (Labs)
P’t problem list and initial plans
P’t progress
Discharge data
Final diagnosis
Discharge medications
Plans for follow-up

21. Suggested Sequence for Presentation of Information
General information (Gen) ↓
Chief complaint (CC)
History of present illness (HPI)
Past medical history (PMH)
Social history (SH)
Family history (FH)
Medication history (MedHx) ↓
Review of systems (ROS)
Physical examination (PE)
Laboratory and diagnostic test results (Lab)
Problem list and initial plans
(SOAP format)
P’t progress to date

22. From database to plan Steps of Systematic Clinical Drug Monitoring
(suggested by Shao C, Chiang, Pharm.D., R.Ph.)

23. (Drug therapy problems )
Problem Conversion
Medical problems (Dx)
Medication problems
(Drug therapy problems )

24. From Database to Plan 1.From data base to assessment SOAP notes
3.From assessment to plan (Implentation)
Therapeutics planning-pharmacist
Diagnostic
Therapeutic (Prescription)
Educational (p’t)
Monitoring

25. 1.From data base to assessment (SOAP notes)
At admission (new p’t)

26. SOAPing Database CC HPI PMH FH SH Med Hx Compliance Allergies ROS PE
Lab tests
X-ray
Scans
Procedure
SOAP notes
Problem list
numbered
acuity/priority
Resolved / inactive
SOAP notes
Implementation of plan
diagnostic
therapeutic
educational (p’t)
Follow-up of progress

27. 2. Assessment
At admission (new p’t)

28. Interpret the Findings in Terms of the Probable Process
Pathological process
Congenital / Inflammatory
Immunological / Neoplastic
Metabolic / Nutritional
Degenerative / Vascular
Traumatic / Toxic
Pathophysiological
Psychopathophysiological
Drug-related

29. Make One or More Hypotheses about the Nature of the Patient’s Problem
Select the most specific and central findings around which to construct your hypothesis.
Match your findings against all the conditions you know that can produce them.
Eliminate the diagnostic possibilities that fail to explain the findings.
Weigh the competing possibilities and select the most likely diagnosis from among the conditions that might be responsible for the patient’s findings
Give special attention to potentially life-threatening and treatable conditions

30. 3.From assessment to plan (Implentation) Therapeutics planning
At admission (new p’t)

31. Components of Therapeutics Planning
* Regimens- initial & alternative

32. The Planning Process Problem identification
Identification of subjective and objective parameters
Grouping of related parameters
Assessment of the parameters and determination of specific p’t problems
Problem prioritization: Identify active and acute problems
Selection of specific therapeutic regimens
Creation of a list of therapeutic options
Elimination of drugs from the list based on p’t-specific and external factors
Selection of dosage, route, and duration of therapy
Identification of alternative therapeutic regimens
Creation of a monitoring plan
Monitoring and modification of the regimens as necessary

33. Common Subjective Parameters
Anxiety
Bloating
Blood-tinged sputum
Blurred vision
Breast tenderness
Chills
Cold intolerance
Confusion
Constipation
Cramps
Decreased appetite
Depression
Diarrhea
Difficulty concentrating
Dry skin
Dysuria
Fatigue
Flatulence
Headache
Heartburn
Heat intolerance
Impotence
Indigestion
Insomnia
Itching
Joint pain
Loss of appetite
Loss of libido
Muscle aches
Muscle weakness
Nasal congestion
Nasal itching
Nausea
Nervousness
Numbness
Pain
Palpitations
Pounding pulse
Rash
Seizures
Shortness of breath
Slurred speech
Sneezing
Sore throat
Syncope
Thirst
Tingling
Tinnitus
Tremor
Vertigo
Weakness
Wheezing

34. Common Objective Parameters
BH and BW
Vital signs
BT, BP, HR, RR
Blood chemistries
Na, K , Cl, CO2, Glu, Scr, AST, ALT, Bil, Ca, Mg, CHL, TG, Alk-P, LDH, UA, BUN
Blood gases
pH, Pco2, Pco2, HCO3-
Blood protein
Total protein, albumin, complements, immunoglobulins
Hematolog
Hb, Hct, MCV, MCH, MCHC, RBC, WBC DC
Urinalysis
Sp. gr, cellular content, protein
Cultures and sensitivites
Blood, urine, sputum, tissue
Serum blood concentrations
Specific organ system tests
PEFR, FEV1, FVC , FEV1/FVC, EF, T3, T4, TSH, Clcr
Miscellaneous
U/O, abd girth, no. of loose stools/day, I/O

35. Factors to Consider when Selecting a Specific Therapeutic Regimen
Patient-specific factors
What regimens have effectively managed the problem in the past？
What regimens have not effectively managed the problem in the past？
How might other patient problems influence the proposed regimen？
How might the proposed regimen influence other patient problems？
External factors
Current “state of the art” therapeutics
Cost of the proposed therapv
Formulary limitations

36. Guidelines for Altering Initial Drug Therapy
If the regimen is ineffective, change the drug if the following are true
The patient received an adequate trial of the drug
The patient received an adequate dosage of the drug
The patient is compliant
If the regimen is associated with life-threatening side effects, discontinue the drug
If the patient is not complying with regimen because of unacceptable side effects, discontinue the drug
If the patient has non-life-threatening side effects and is willing to continue the drug,
minimize the side effects by doing the following:
Adjust the dosage of the drug
Change the timing of the dose

37. 3.From assessment to plan (Implentation) Monitoring
At admission (new p’t)

38. Patient-Focused Care Cycle A Never-Ending Cycle
Data acquisition
and assessment
Problem identification
and prioritization
Therapeutic
planning
Patient
monitoring
Patient-Focused Care Cycle A Never-Ending Cycle

39. The Process of Monitoring Therapeutic Regimens
Set therapeutic goals
Determine patient- and drug-specific monitoring parameters
Integrate the monitoring plan
Obtain data
Assess the response to therapy
Alter the therapeutic regimen if necessary
Repeat Step 1-6

40. Organization of Monitoring Parameters (The Four-Square Method)
Subjective-Therapeutic
Subjective-Toxic
expected therapeutic outcome
indicating therapeutic failure
or harm
Objective-Therapeutic
Objective-Toxic

41. Steps of systematic clinical drug monitoring at inpatient setting
Hospital stay (old p’t)

42. Hospital Stay Daily SOAP note Daily drug monitoring
Each problem has its own SOAP note.
The subjective and objective data should include the values of drug monitoring parameters.
All problems should be assessed and planed, unless the problem has been resolved
Daily drug monitoring

43. Real Practice Setting
With time and practice, the process of assessing patient therapy and prioritizing the need to make an intervention becomes second nature and does not require a concerted effort to mentally check off each step after it has been performed.
Setting priority about which patients require more in-depth intervention.

44. SOAPing format

45. SOAPing Format SOAPing A formal organizationl structure Steps
The process of identifying the subjective and objective data, assessing the problem, and developing a specific therapeutic and monitoring plan
A formal organizationl structure
Steps
Creation of a list of related subjective parameters
Creation of a list of related objective parameters
Assessment and documentation of the problem
Documentation of the therapeutic plan for addressing the problem

46. Thinking Process Tips Problem identification Desired outcome
Therapeutic alternatives
Optimal plan
Outcome evaluation
Patient education

47. Problem List Current medical problems Goal of therapy
Measurable endpoint

48. SOAPing Format USC School of Pharmacy Kathleen Besinque Pharm D, MS Ed

49. Current Drug-Therapy Problems
Subjective and Objective
Problem (subjective and objective)
Current medication
S: CC:
Pertinent medical Hx:(HPI / PMH)
ROS:
SH:
FH:
Allergies:
ADR:
Drugs
OTCs
Herbal O:
(PE /Labs)

50. Current Drug-Therapy Problems
Assessment
Etiology
(or risk factors)
Evaluate need for therapy; evaluate current therapy (Evidence need for therapy evaluation)
Drug therapy problem 1
CPG1
Class of drugs
Drug therapy problem 2
CPG2
Drug therapy problem 3
CGP3

51. Current Drug-Therapy Problems
Plan
Recommended drug treatment, drug to be revised, further test
Goal and monitoring parameters (toxic and therapeutic)
Patient education
Recommend 1
Item of drugs
Goal 1
Therapeutic
Toxic
Education 1
Recommend 2
Goal 2
Education 2
Recommend 3
Goal 3
Education 3

52. (Drug therapy problems)
Problem Conversion
Medical problems (Dx)
Medication problems
(Drug therapy problems)

53. 教學時遭遇的困難與處理

54. 教學時遭遇的困難與處理 (1)
藥師指導 clinical drug monitoring 及 case presentation 之技巧有差異
參與醫院藥學實習指導師資認證訓練課程
閱讀病歷抓不到 (困難擷取)藥事服務所需資訊
Medical problem (Dx) Medication problems
(Drug therapy problems)
病歷上少有藥師的記錄或看到daily SOAP note
持續練習就能習慣
如何釣魚需由作中去領悟

55. 教學時遭遇的困難與處理 (2) 教學過程多是由指導藥師來告訴答案 藥師在藥事服務介入的時間多於學生 報告時間的壓力 學生常是事到臨頭才要做
學生難於確認那麼多Drug therapy problems
臨床教學模式
常是糾正學生的錯誤, 解釋處理Drug therapy problems的原則
已修過藥物治療學 / 臨床藥學課程者再實習
病案報告非 concurrent case
藥師需作調劑工作
藥師未全程參與病患照護
難了解醫師對藥師意見的接受度及藥師建議的可行性

56. 結論 Problem oriented drug monitoring 有清晰的邏輯思考
可解決複雜的Drug therapy problems
本課程是建立思考邏輯
沒有絕對標準的答案
引導學生/藥師的指導藥師-很重要

57. Case Example(案例說明) Hypertension

58. 課程目標(HTN) Establish goals for the treatment of HTN.
Choose appropriate lifestyle modifications and anti-HTN based on patient-specific characteristis and concurrent disease states.
Design appropriate monitoring plans for pts receiving anti-HTN therapy, including laboratory parameters and time intervals.
Modify pharmacotherapeutic regimens for pts who experience adverse events or do not have adequate BP reduction on an initial regimen.
Provide appropriate patient education for anti-HTN regimens.

59. Patient General Information (Gen) 病患基本資料
Patient name: 王先生
Chart no: xxxxxxxx
(Bed no: xxxx-x)
Address: 台南市信義路
Age: 79
Height: 175 cm
Sex: M
Marriage status: married
Weight: 95.4kg
Allergies: NKDA
Date of admission (DOA) : yy mm dd

60. Chief Complaint (CC) 病患主訴病情
王先生 is 79-yo male seen in the ED with respiratory distress with severe dyspnea and wheezing.

61. History of Present Illness (HPI) 發生現在疾病之病程
王先生 was coming home from the grocery store when he became short of breath and wheezing carrying in his groceries.
He could only say a couple words between breaths. His neighbor noticed him in distress and called 911.
王先生 experienced severe shortness of breath 6 months ago and was hospitalized for acute severe asthma.

62. Past Medical History (PMH) 過去病史
Diagnosis with asthma approximately 20 years ago, rheumatoid arthritis about 5 years ago, and benign prostatic hyperplasia last year.
Patient using a herbal product to treat his benign prostatic hyperplasia.
Admitted to hospital 3 times in the past 2 years for exacerbation of asthma.
Previous office visit 5 weeks ago, documented a blood pressure reading of 150/95 mmHg.

63. Social History (SH) 個人生活史
Tobacco use: 1/2 pack/week
Alcohol use: Six pack per week
Caffeine use: 2 Cups of coffee every morning

64. Family History (FH) 家族病史
Mother died of an MI at age 68.
Father died of lung cancer at age 75.

65. Medication Record (Prescription and OTC) (MedHx)用藥史
Furosemide 40 mg po q AM
Albuterol inhaler 2 puffs qid prn
Beclomethasone inhaler 1 puff qid
Ibuprofen 800 mg po tid
Herbal product with licorice po qd
Acetaminophen po prn

66. Review of Systems (ROS) 現有疾病或問題 (HPI 除外)
Wheezing and coughing

67. Physical Examination (PE) 身體診察
VS:
BP 160/100 mmHg
HR 120 beats/min
RR 31 rpm
T 38.5℃
Ht 175 cm
BW 95.4 kg
BMI 31.2 (95.4/1.75x1.75)
CHEST: Expiratory wheezes

68. Laboratory and Diagnostic Tests (Labs) 檢驗數據及檢查報告
Potassium
3.8 mEq/L
Sodium
145 mEq/L
Serum creatinine 1 mg/dL
FBG
100 mg/dL
Total cholesterol 200 mg/dL
HDL
35 mg/dL
RBC
4.7 cells/mm3
Hgb 15 g/dL
Hct 44% PH
7.40
PaO2
55 mmHg
PaCO2
40 mmHg

69. Diagnosis 診斷 Primary: 1)Asthma 2)Hypertension Secondary:
1)Benign prostatic hyperplasia
2)Rheumatoid arthritis
Problem list

70. Problem List Current medical problems Goal of therapy
Measurable endpoint
Primary:
1)Asthma
Symptom control
Prevent asthma episodes or attacks
PEFR
No DOE, SOB, PND
2)Hypertension
Prevent CHD, Stroke and Nephropathy BP
Secondary:
1)BPH
DRE (digital rectal exam)
UFR (urine flow rate)
2)RA
Improve QOL
Arrest or retard disease progress
Swollen & tender joints
RF, ESR, ANA, CBC
X-Ray

71. Current Drug-Therapy Problems
Subjective and Objective
Problem (subjective and objective)
Current medication
S: Pertinent medical Hx:Asthma x 20 yrs; RA x 5 yrs; BPH x 1yr
ago; HTN x 5wks
ROS: respiratory distress with severe dyspnea ; wheezing and
coughing
Tobacco use: 0.5 pack/week ; alcohol use: 6 pack / week ;
caffeine use: 2 cups of coffee every morning
Use a herbal product to treat his BPH
Furosemide 40 mg po q AM
Albuterol inhaler 2 puffs qid prn
Beclomethasone inhaler 1 puff qid
Ibuprofen 800 mg po tid
Herbal product with licorice po qd
Acetaminophen po prn O:
175cm , 95.4kg HR:120 BP:160/100 RR:31 T38.5℃
Expiratory wheezes
PH 7.40; PaO2 55; PaCO2 40
Admitted to hospital 3 times/past 2 yrs for AE of asthma
BP 150/95 mmHg previous office visit 5 wks ago

72. Current Drug-Therapy Problems
Assessment
Etiology
(or risk factors)
Evaluate need for therapy; evaluate current therapy (Evidence need for therapy evaluation)
AE of asthma
Primary therapies for AE (most safely undertaken in a hospital or hospital-based ER)
Repetitive administration of rapid-acting inhaled β2-agonist
Early introduction of systemic glucocorticosteroids
Oxygen supplementation
Closely monitor response to treatment with serial measures of lung function
Inadequate response to treatment for HTN
D/C herbal product with licorice ( has been shown to have an aldosterone-like action)
Both ibuprofen and licorice can cause an inadequate response to HTN therapy
If BP remains elevated, the clinician should consider initiating anα-blocker
Inadequate BPH treatment
The preferred therapy for this pt may be α-blockers (the favorable effects on prostatism and dyslipidemia-decrease LDL-C and increase HDL-C
Postural hypotension is commonly experienced withα-1 blockers because of the direct action
The “first-dose phenomenon ” is characterized by transient dizziness,faintness, palpitations, and syncopy occurring within 3 hrs of the first dose.

73. Current Drug-Therapy Problems
Plan
Recommended drug treatment, drug to be revised, further test
Goal and monitoring parameters (toxic and therapeutic)
Patient education
IV methylprednisolone mg or Hydrocortisone mg ; or oral prednisolone mg/kg for 7-10 days
Decrease symptom
PEFR
(GINA 2004)
Report any  in SOB, DOE, PND Techniques in use of medications
Smoking cessation
D/C herbal product with licorice
BP check daily
BP in 1wk < 140/ 90 (JNC VIII)
Teach pt how to self measurement of BP
Remind pt that home measurement device should be checked regularly for accuracy
Lifestyle modification recommendations
(5 modifications)
Usual dose :
Prazosin 2-30 mg ,bid-tid
Terazosin 1-20 mg ,qd-bid
Doxazosin 1-16mg ,qd
(first dose at hs)
(bladder outlet
obstruction, postvoid
residual urine
volume, reverse urinary
retention / RI
May be avoided by having the pt take the first dose and/or the first increase in dose at bedtime

74. 尾端 Un Clos (A Close)-塞尚 Cezanne 1890
謝謝聆聽 敬請指教

75. 時間分配 9:20 ~ 10:50 分組討論與演練 10:50 ~ 12:00 各組心得分享
9:20 ~ 10:50 分組討論與演練
10:50 ~ 12:00 各組心得分享
第一組報告 10:50 – 11:00 ~ Type 2 DM--initiate OADs in a newly diagnosed DM patients
第二組報告 11:00 – 11:10 ~ Hypertension--inappropriate drug of choice and inadequate BP control for HTN
第三組報告 11:10 – 11:20 ~ Hyperlipidemia--initiate lipid lowing agents for a patient with high CV risks
第四組報告 11:20 – 11:30 ~ Obesity, metabolic syndrome--pharmacotherapy of obesity and metabolic syndrome
第五組報告 11:30 – 11:40 ~ 案例各問題補充報告
第六組報告 11:40 – 11:50 ~ SOAP格式心得報告
11:50 ~ 12:00 輔導員分享

76. 其他注意事項
雖然有主題報告，仍有學員不熟悉SOAP，有時需解釋並分辨哪些屬於"S"、哪些屬於"O"、哪些屬於"A"、哪些屬於"P"，請在課程報告中詳述佐以實例說明。
學員大部分都很怕講錯，一定要讓學員了解，課程是要訓練他們熟悉寫SOAP的思考模式和流程，所以上課時不要太在意所提出的"PLAN"對不對，而輔導員或主持人在講評時也儘量針對SOAP本身就好（除非真的建議的內容太離譜啦~）。
雖然練習的個案資料內容很豐富，但是要提醒學員在實際臨床時，有些資料不是光靠病歷閱讀來取得，尤其是針對藥物的部分（過去用藥史，有病史為何未用藥？...等等）。
善用手冊的SOAP表單，更能掌控A、P呈現的重點。
註：請參考輔導員帶領小組討論的技巧與注意事項