2_Communication Strategies in Pharmacy 3 of

Terms in this set (239)

Opening question: Usually is open ended ("Tell me about your stomach problem").
b. The PQRST (Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity, Timing/
Temporal relationship) method after the patient's opening story encourages a comprehensive
description of the problem. Commonly used for pain but also suitable for a variety of problems.
i. Provocative or palliative: "What makes the problem better (or worse)?
ii. Quality or quantity: "How many times...?" "Describe the sensation."
iii. Region or radiation: "Point to where you feel..."
iv. Severity: "On a scale of 1-10, with 10 the worst, how bad is this?" "How does this compare to
usual (state of health)?" "How bothered are you by this problem?"
v. Timing/Temporal relationship: "What time did this start?" "How long after you started
exercising did...?"
c. A variant used for hospice palliative health is the OPQRSTUV method. The additional portions
may be useful in other situations as well.
i. Onset of the problem
ii. Provoking/palliating
iii. Quality
iv. Region/radiation
v. Severity
vi. Treatment: "What have you tried so far?" "What has been the effect?" "Has this treatment
caused any problems?" "What have you used in the past?"
vii. Understanding impact on you: "How is this affecting your daily activities?" "What has been the
impact on your family?" "What do you believe is causing this problem?"
viii. Value: "What is your goal for this problem?" "What would be an acceptable level for this
ix. (www.fraserhealth.ca/media/SymptomAssessmentRevised_Sept09.pdf)
d. Follow-up or other visits without a chief concern, start with open-ended questions to begin dialogue
about what patient hopes to accomplish at this visit.
e. The Background, Affect, Troubling, Handling, Empathy (BATHE) method can be useful to gather
data and the patient's perspective on problems that have an emotional component or that affect
quality of life. For example, identify how a patient is coping with a new diagnosis (Prim Care
Companion J Clin Psychiatry 1999;1:35-8).
i. Background: Use an open-ended question similar to the standard question to elicit the chief
ii. Affecting: Solicit feelings or effect on quality of life. "How do you feel about this?" or "How is
this problem affecting your life?"
iii. Troubling: Identify the relative importance or specific areas of concern. "What troubles you the
most about...?
iv. Handling: "How are you dealing/coping with this problem?"
v. Empathy: Reflect back the concern and/or emotion. "You seem frustrated by the lack of..."
vi. The BATHE method should be used in severe situations (e.g., when the patient is in extreme
pain, when the patient is psychotic or suicidal).
(a) The BATHE technique is a psychotherapeutic procedure, meaning it seeks to empower
patients to trust themselves and others, confirm their positive feelings about themselves,
and enhance their ability to control the circumstances of their lives.
(b) This method will also serve as a rough screening test for anxiety, depression, and situational
stress disorders.
Brief the interpreter about the purpose and goals for the encounter
Verify that the interpreter will function in a conduit manner (i.e., interpret in the first person without revising,
adding, or deleting any of the message)
Face the patient, make eye contact with the patient, and talk by using the first person
Use a normal speaking tone and volume
Expect that the interpreter will do the following:
• Greet the patient and introduce himself or herself at the beginning of the encounter
• Transmit any exhibited emotion (by you or the patient)
• "Step out" of the interpreter role to ask his or her own questions of you or the patient if the interpreter does
not understand what is being said
• Stand off to the side so that the facial expressions of both parties can be seen
Use normal good communicate strategies; for example:
Use lay language; the interpreter will not simplify your words
Check patient understanding by using the teach-back or show me techniques
Be aware of the policies in your institution for using bilingual colleagues as interpreters; asking colleagues to
function outside their normal training and responsibilities can be problematic (e.g., asking a receptionist to translate
a diabetes education session)
Avoid using family members or friends of the patient to interpret
• They may have conflicts of interest or trouble being objective
• They may have difficulty understanding the information to be translated
• Document the patient's requests to use the interpreter of his or her choice
• If a family member or friend functions as an interpreter, first assess his or her English proficiency with
informal conversation; then, assess his or her health literacy with a basic question related to the encounter
• Be specific with expectations for accurate, complete translation of words from both the patient and the
• Use minors only in emergencies
Document in the medical record that an interpreter was used, together with his or her name and that of his or her
Do your homework before making the recommendation.
a. Hypothesize the reasons that this situation occurred. Is this likely an oversight or an intended
choice by the prescriber? Identifying the possible reasons will help you to anticipate and respond to questions or requests for additional information.
b. Is additional information needed to assess the situation, such as blood work or information from the patient history?
c. Identify and weigh therapeutic alternatives to identify the best recommendation to resolve the
situation. What is the strength of the evidence to support each recommendation? How might the
recommendation change depending on the additional patient information requested?
d. Consider to whom you will be communicating the recommendation. Knowing your audience will be helpful in framing your recommendation. What will they know or want to know?
i. Discipline: Physicians, nurse practitioners, and physician assistants will generally have a
different level of knowledge of therapeutics and evidence-based medicine.
ii. Generalist versus specialist: Is this therapeutic recommendation within or outside their area of
iii. Academic versus nonacademic provider: Academicians may have a greater interest in detailed rationales and the results of clinical research, and they may be open to new evidence. However, they may also be more skeptical of suggestions from those outside their discipline or specialty.
iv. Personality of the provider (e.g., confidence in their ability, openness to new ideas)
v. Differences in communication styles: According to cultural or ethnic background, age, sex, or
generational differences
e. Choose an appropriate time: What is the level of urgency? When is a good time to talk?
(e.g., "Is this a busy time for you?")
f. What is the optimal method of delivery (e.g., written, verbal, or electronic)? Ideally, verbal
recommendations should still be documented as a note in the patient's medical record.
Be clear, complete, concise, timely, professional, and organized.
a. Introduction
i. Greet the provider by the preferred method of address. Always use a formal greeting (e.g.,
Doctor) if a third party is present.
ii. Identify yourself and your role, if necessary.
iii. The opening should catch the provider's attention and signal the level of urgency. What do you want the provider to do?
b. Define the problem or issue. Support the assessment with patient-specific data.
c. Clarify the problem or request additional information. Be prepared to modify your recommendation according to this new information.
d. Suggest a solution (with any acceptable alternatives) to the problem. If there are several suitable alternatives, present them objectively.
e. Use an appropriate verb according to the strength of your recommendation (e.g., recommend, suggest, consider).
f. Provide the rationale and offer evidence to support the recommendation. Clearly separate opinion from published evidence or guidelines.
g. Develop rapport while delivering the interventional message. Watch the terminology, tone, and body
language.i. If the message is delivered verbally, choose a time that is as convenient as possible (e.g., if
nonurgent, wait for the provider to finish current task or ask to speak with the provider after
rounds are completed).
ii. The message should be patient focused rather than about organizational policy (e.g., explain
why your recommendation [based on this policy] would improve the care of this patient).
iii. Be calm, respectful, and assertive, but not aggressive. Include patient data to support
iv. Be tactful. Phrase the recommendation positively. How would this change benefit the patient?
v. Be persuasive, but do not overstate the case for change.
vi. Use of correct medical terminology, pronunciation, and confident body language will add to
credibility. Avoid nervous mannerisms.
vii. Revise delivery according to the cues and body language of the provider (e.g., shorten the
conversation if the provider appears stressed or hurried).
h. Be prepared to modify your recommendation in response to new information or challenges from the provider.
i. Answer questions and offer further explanation. Elaborate on justification.
ii. Collaborate to identify the best alternative. Sometimes, the best solutions are completely
different from the initial recommendations and arise from the synergy between the pharmacist
and the provider.
iii. If the recommendation is partly accepted or rejected, advise whether further or more frequent
monitoring might be necessary to avoid future problems.
1. Be clear and concise yet complete. Note should not require further verbal explanation
(e.g., "Renewed lisinopril 10 mg daily for 3 months" is better than "Refilled lisinopril x 3").
2. Be appropriate for all likely target audiences (e.g., prescribers, nurses, physical therapists, dietitians).
3. Include the necessary information to be interpreted within the short- and long-term time context in which
they were written. For example, "Pending the return of cultures, the empiric antibiotics started are...";
"Awaiting information from the family to clarify drug dose"; "Current first-generation cephalosporin on
formulary is..."; "According to the Third Expert Panel Report on Asthma guidelines, suggest..."
4. Include the time and date of the note (unless already electronically time stamped).
5. Write tactfully and persuasively. Document the patient's concerns, health beliefs, and reasons for
declining therapy in a nonjudgmental manner. Objectively document the results of interactions with
other health professionals; do not be critical.
6. Use professional terminology and format.
7. Document in a timely manner
8. Be transparent when making addendums, corrections, or changes
9. Record formal names and the disciplines of the colleagues involved (e.g., "Referred to S. Jones, RD, for diabetes diet instruction").
10. Include documentation of even brief interactions, such as telephone calls.
11. Write legibly in paper charts. Be especially careful with writing numbers and inserting decimal points. Rather than squeezing in information, start a new page.
12. Tips for electronic charting
1. Subjective data obtained from patient interviews, medication histories, and results of medication reconciliation should be documented in the medical record as discussed previously (e.g., adherence behaviors, results of SILS or other health literacy assessments, misperceptions, personal goals and health beliefs about medications, preferred learning styles).
2. List the educational content, skills taught, and verification of the patient's understanding at the highest level appropriate for that content.
a. "Patient verbalized/indicated understanding of..." is generally an inadequate verification of
understanding. "Indicated" could merely mean the patient nodded, said "I understand," or just did not have any questions.
b. The minimum level of understanding that should be documented is comprehension (e.g., results from teach-back method). For example, "The patient repeated the new warfarin dose and that she is to return for blood work next week."
c. Ideally, any required skills should be demonstrated by the patient (e.g., using the show-me technique).
For example: "Patient correctly showed 8-mg dose from combination of 5-mg and 1-mg warfarin tablets." "Patient obtained an adequate blood sample and correctly recorded the blood glucose reading."
d. If the instructions are situation-dependent, the documentation should state the patient's ability to
apply the information (e.g., "Given peak flow and symptoms, patient was able to identify the correct zone and corresponding activities on the asthma action plan").
3. Document both the educational message and the implications for adherence/nonadherence if applicable.
For example, "Patient voiced reluctance to return for blood monitoring. Explained the importance of frequent blood work and medication adjustments to minimize the risk of significant bleeding."
4. Further educational needs and plans for follow-up. Note the patient's level of difficulty or ease in learning new skills and any particular steps with which the patient struggled. For example: "Patient demonstrated correct inhaler technique on first attempt" or "Patient struggled with timing of the inhalation to the release of medication."
5. Any specific educational materials or resources such as written pamphlets given (e.g., title and source of material, referrals to websites or support groups). For example: "Patient given American Heart Association pamphlet 'What Is Hypertension?'" If several versions exist, the version or revision date should be noted.
1. Provide sufficient patient data to support the assessment and plan.
2. Assessments should be clear and consistent with patient's data. Use appropriate terminology for the disease (e.g., "Patient has stage II hypertension, uncontrolled to goal pressure of..." "Carvedilol is an appropriate β-blocker for heart failure, but current dose is below target of...").
a. Use of ICD-10 terminology
b. Complete assessments will support higher billing codes based on patient acuity
3. Making written recommendations
a. Use the active voice whenever possible. The note should reflect the writer's professional opinion, not that of others. For example, "I recommend..." versus "It was decided..."
b. Choose a verb that corresponds to the strength of the recommendation (e.g., recommend, suggest, advise, consider).
c. Be specific (e.g., the complete drug regimen, the person who will follow up, what blood work was ordered, time frame for monitoring).
d. Clearly document the results of the recommendations; for example:
i. Whether recommendations were accepted and whether there were any order changes
ii. When recommendations are partly accepted or rejected
(a) Document respectfully and objectively. As stated previously, the active voice is usually
preferred. However, the passive voice can be useful in situations when one wants to
document one's recommendation and acknowledge provider's decision without reflecting
one's agreement with it. For example, "Suggested that the ramipril dose be decreased to 5
mg because of rising serum potassium (now at 5 mEq/L). Checked with Dr. Jones. Ramipril
to be continued at same dose (10 mg) at this time. Serum potassium to be checked again
tomorrow." (passive voice)
(b) Document actions taken to limit the potential for adverse effects. "Verbal order from Dr.Jones to recheck potassium in 3 days and decrease the ramipril to 10 mg daily if still greater than 5 mEq/L."
1. Can be influential and highly visible in local newspapers. Often written in response to the paper's editorial or can be unsolicited on a timely topic.
2. A limitation is that only a few are published compared with letters to the editor.
a. Timing is critical. Today's top story is old news tomorrow. Submit quickly if you wish to respond to an editorial or hot news item. If a topic is likely to be brought up in the near future, you might draft a piece in anticipation and then tailor it to the actual event.
b. Be concise and to the point. Keep the length to a maximum of 600-750 words.
c. Make one carefully crafted main point. Be clear and accurate with facts and evidence.
d. Help the readers care about the issue. A personal story about yourself or a patient situation provides human interest. (Be careful to protect patient privacy in examples.) Use an example that readers can understand and that is memorable.
e. Write it for a lay audience: Follow the suggestions in the Health Literacy section on written materials (e.g., use short sentences and common words, avoid jargon and abbreviations, use an active voice).
f. Follow the rules and guidelines from the newspaper or media source (e.g., length, to whom it is sent, whether or not to use an attachment, preferred method of submission).
g. Write a cover letter with key points, state why this topic is timely, and provide your credentials.
h. Make a favorable first impression and a memorable last impression. A catchy opening grabs attention, and a good closing is what the reader may remember.