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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: s_tunpichart@yahoo.com
(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
- Metformin 500 mg 1 X 2 pc 1 X 1 pc
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
- Metformin 500 mg 1 X 2 pc 1 X 1 pc
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
- Metformin 500 mg 1 X 2 pc 1 X 1 pc
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
(Pharmacist Referral Assessment: RRA)
83
5. (Referral Assessment: RRA)
2
1. RRA (Pharmacist Referral Assessment)
2. PRF (Physician Responded Form)
84
31 . . 2553
(Pharmacist Referral Assessment: RRA)
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
(Pharmacist Referral Assessment: RRA)
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
87
2
88
(Drug related problems)
2
,
1. 3 2. 1 3. 1 4. 6 1
. 3
.
:
: 1. 2.
3. 4.
5. 6.
89
3
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
? - /
, , ,
- ?
- ?
- - , ,
? - , , ,
? - ,
,
95
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
(Pharmacist Counseling Profile: RCP)
RCP1: , RCP2:
: / / .
(Lifestyles, Clinical symptoms, DRPs)
(Actions)
(Plans)
.
- -
105
(Pharmacist Counseling Profile: RCP)
RCP1: , RCP2:
: / / .
(Lifestyles, Clinical symptoms, DRPs)
(Actions)
(Plans)
.
- -
106
(Pharmacist Counseling Profile: RCP)
RCP1: , RCP2:
: / / .
(Lifestyles, Clinical symptoms, DRPs)
(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 : panchaya_2@yahoo.com
: 1 2553 : 500
: . 1209 . 94 . 10310 0-2538-4906, 0-2539-4450 E-mail : s_tunpichart@yahoo.com
: 1/20 . 10310 0-2277-5488, 0-2693-0048 E-mail : phar_macy@hotmail.com www.qpharm-network.com
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