Patient chart

Traditionally different paper patient chart order systems have been used for documentation of all activities planned and performed. For each patient this could be hundreds and sometimes thousands of papers sorted by care occasion for each level of care. Also the documentation is sometimes incomplete and historical events and circumstances are hard to find. Recently some aspects of patient care such as laboratory lists and other tests and results have been included in electronic systems. Since medication chart orders belong to the most complicated issues this is often the last to be integrated. 

The next types of clinical services along the continuum are those which pertain to disease-state management. These services occur separately from the dispensing function over an extended period but have an added feature of ongoing patient education and an extensive review of drug therapy as it relates to attainment of the patients therapeutic goals. A comprehensive patient chart is created, patient sessions may last from 15 to... 

After performing a SWOT analysis and some baseline market research, Carol and the other pharmacists at Care-Rite Pharmacy have decided to develop a Pharmacy Check-up Service (MTM). One of Carol s pharmacists volunteered to put together a prototype patient chart that will be used by the pharmacists to document their activities. The patient chart contains several forms, including a patient history form that requests some basic demographic information (see Fig. 25-2), medical and medication histories forms (see Figs. 25-3 and 25-4), and an authorization to release medical information that is signed and dated by the patient (see Fig. 25-5). Also, a communication form was created to fax clinical information and pharmacists recommendations to the physician (Fig. 25-6). 

The main patient outcome measures of interest to the pharmacists at Care-Rite Pharmacy are clinical outcomes, patient knowledge, and patient satisfaction. Also, the pharmacists were interested in monitoring physician response to their clinical recommendations. The information collected would be kept in the patient chart. An electronic database was created to store... 

The documentation will occur via a patient chart. Subjective patient information and objective laboratory data will be stored in the chart. Assessments of patients during the clinic visit will be documented in pharmacy progress notes contained in the chart. Acceptance of pharmacy recommendations by physicians will constitute an order change, and this will be documented in the patient record as well. Lasdy, patient... 

Cynthia Marshall is a pharmacist who works at a closed-staff-model health maintenance organization (HMO) pharmacy. Pharmacists at this clinic have access to patient charts that can be used to supplement information given by the patient to the pharmacy staff and what is written... 

Reads, extracts, and interprets information in patient charts and electronic databases accurately. 

Raw data Researcher s records of patients, such as patient charts, hospital records, X-rays, and attending physician notes. These records may or may not accompany an NDA, but must be kept in the researcher s file. The FDA may request their submission or may audit them at the researcher s office. 

For professionals who work in the same setting, the rules around confidentiality are less clear, particularly when patient charts contain both medical and mental health notes. Treatment teams in the same setting could assume that a free exchange of information is allowed and necessary. We agree, but we also believe that making this policy explicit to the patient and family is important. Case notes are especially vulnerable to mishandling. For example, there is always a chance that mental health notes that are part of the medical record could be unintentionally released to a third party. If expectations are communicated and understood among the patient, family, therapist, and physicians, confidentiality need not impede collaboration (see Tables 10.3 and 10.4). Furthermore, collaboration need not violate confidentiality. 

Before these schemes were introduced, patients were asked to bring any medication they were taking into hospital so that doctors could gather an accurate patient medication history upon admission. This information was transferred to the patient s in-patient chart and subsequent administration of the medication in the hospital took place either via ward stock or patient-specific in-patient orders (see Section 4.2.1). Upon discharge, patients were given a standard 14-day supply of medication via a TTO. In many cases, the patient s original medication was not returned to them and was just discarded. 

In-patient orders check against in-patient chart TTOs check against in-patient chart... 

Interactions There is only one drug on the TTO. However, it would also be advisable for the pharmacist or pharmacy technician to check the patient s in-patient chart for any concurrent medication that could cause an interaction. Although a patient would need to continue to take all prescribed medication upon discharge, they may already have enough of some medication and therefore that medication may not appear on the TTO. This situation is especially likely to occur if the patient is part of a patients own drugs scheme (see Section 4.2.2). 

The form of the medication to be supplied has not been stated. As the product comes as both tablets and capsules, it would be necessary for the pharmacist or pharmacy technician to check with the patient s in-patient chart to ascertain the form of the medication taken to date. 

The in-patient order would be sent to the pharmacy and the pharmacy technician would dispense two amoxicillin 3 g sachets and send to the ward (once checked), labelled with the patient s name. As the medication will be administered by the ward s nursing staff according to the directions on the in-patient chart, it is not necessary to include administration details on the label. 

The PI is responsible for maintaining records associated with the clinical study. These include case histories designed to record all observations or other pertinent data on each enrolled subject, independent of whether the subject received active treatment. Data for each trial subject is normally recorded on a case report form provided by the sponsor. The sponsor may also require study data to be recorded in a source document (patient chart). It is the responsibility of the PI to assure that the forms are filled out with the correct information and according to guidelines established by the sponsor. 

In a prospective study to evaluate the impact of a clinical pharmacist in outpatient hematology-oncology clinics, patient charts and profiles were reviewed and patient interviews were conducted to obtain medication historiesWithin a 36-day time period, 211 interventions were documented the majority of these interventions were not related to chemotherapy. The most frequent activities consisted of patient counseling and therapeutic recommendations. Of the problems identified, most were of high and moderate significance and pharmacy interventions yielded positive clinical outcomes. The physician acceptance rate to pharmacists interventions was 94.5%. 

Pharmacy Technician Most pharmacists rely on pharmacy technicians to prepare the proper medications to fill prescriptions. These technicians read patient charts and prescriptions in order to prepare the proper concentration, or dose, of medication that is to be administered to patients. For more information on chemistry careers, visit glencoe.com. 

From the time a patient is admitted to the health care organization until the time the patient is discharged, there are many transactions that take place. These may include assessments, me cations, laboratory tests, and diagnostic and therapeutic procedures. Each transaction generates aresult, which may be in the form of numbers, images, reports, or the administration of a therapy. Transactions may be interdependent, in that subsequent transactions are based on the results of previous transactions. Such processes generate a longitudinal record that profiles the activities and results associated with a particular patient. In a paper world, this is the patient chart, which, if implemented in an electronic context, becomes the electronic patient record. 

The shortcomings in these areas include incomplete and inconsistent medication history in patient charts, pharmaceutical care not provided routinely, large number of abbreviations used on preprinted forms and in medication communications (verbal and written), medication brands changed without the knowledge of surgical teams or technicians, hazardous chemical found in close proximity to products designated for patient use, top of anesthesia carts cluttered, medication "stashes" found in selected areas, inconsistent preoperative teaching of patients, and inconsistent system of double-checks [10]. 

Supportive therapy, intravenous fluids, and hemodialysis are the hallmarks of treatment for lithium toxicity. In a retrospective review of patients charts the cation exchanger sodium polystyrene sulfonate (Kayexalate ) was compared with supportive treatment in 48 patients with chronic lithium toxicity [65 ]. Sodium polystyrene sulfonate is given orally and binds... 

Some studies have demonstrated the relationship between hypertension and peripheral vascular disease by looking at higher risk populations, e.g., the elderly. Ness et al. f 20), in a retrospective analysis of older patients charts seen from January 1,1998, through June 15,1999, at an... 

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