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The process of pharmacist clinic service and standard operating procedures

And, this is a very big flow chart. It’s talk about how do we manage our patient once it enroll in our anticoagulation clinics. For example, this is a warfarin cases. Once the patients go through the initial referral, it can choose to returned visits, it is the face-to-face communication
or the patient can choose: I want to do the telephone follow-up. Then, we will arrange a time and make a phone call to the patient. And, we do it every 3 months in the follow-up services. If the patient has INR unstable or they have adverse drug reaction or they are in hospitalization and it is warfarin related. Then, we will give feedback to the doctors and we suggest the patient return to the anticoagulation clinic as soon as possible. If the patient is in our hospital, we will go to the bed site and talk to the medical team for the further treatment.
And, during this returned visits, our telephone follow-up if the patient condition is warfarin regimen is finished, or it shift to the NOACs, or it shift to antiplatelet or it shift to other health care units, or it is death or lost of contact. Then, we will close the case. And, this is the best outcome we want to know is that once we follow up the patient for 12 months, and the TTR% is over 70. That means this patient is in very good anticoagulation management.
Then, we will tell the patient that : congratulation. In the past year, you have in a very good condition then you can return to the doctor’s clinics and you are in good hands. And, if it is the last situation. It is that we follow up for one year, and another two additional phone follow-up, no matter what, the case is finished and the doctor take over the patients. And, this is the situation that if the patient return to anticoagulation clinics after case closed or finshed over 6 months, and they will enroll as initial referral.
The pharmacists have to go through a fresh new patient because it must have a major problem that is not detected in the previous service so that the patient have to come back to our clinics. Once they finish their treatment course. Once we go through the work flow of warfarin, then we go to the NOACs service. Basically, it is same idea with warfarin, but there is the differences that for the patient condition during the follow-up appointment. If they have the severe renal function decline, then we have to give the notice to the doctor. Because NOACs is basically unlimited by renal function. It depends on the renal function.
So, If the patient takes NSAIDS and cause acute kidney injury, then we have to inform the doctor so that it can adjust the regimen of NOACs.
Then, we need to set up service standard, which is SOP. It will include that how pharmacists do the patient interview, and it also include professional adjustment. And, it need to include how pharmacists doing their pharmacy note and update the recent guidelines. And, it also include the personnel training and the service SOP can be facilitated by technology.
This is our anticoagulation clinic system. It’s the system that facilitate our service SOP. It is a question-guided patient interview, So, the pharmacists just go one by one question, and you can finish patient interview following. And, this system have the full done menu So, pharmacists do not have to tie on medical record and documentation. It only has to give a quick the platform and the system will generate standard pharmacy S.O.A.P. It is very save your time on documentation.
And, this clinic system will also have auto-import lab data. It will help you to manage your lab data and auto-calculated TTR%. TTR% is a surrogate to AC performance. And, usually in the previous time, we take a lot of time calculating the TTR one by one by our bare own hands. But now, we have the system to help us calculate the TTR% just in a click. And, the patient will know their TTR% during their appointment and it will help patient to go with our treatment plan.
And ,in our system, it also has a auto-calculated risk evaluation. In patients with atrial fibrillation, we need to calculate the CHA2DS2-VASc score for stoke risk evaluation and HAS-BLED for bleeding risk evaluation. Under these two evaluation method, you can have the same page with the patient.
The patient will know that: Oh, my CHA2DS2-VASc score is high So, I need to take the anticoagulant prevent the potential stroke. And, once he knows this fact, he will be willing to take the medication and increase the medication adherence. And, if the patient know that I have high HAS-BLED risk, my HAS-BLED risk is high, then my bleeding tendency is high. So, the patient is more willing to adjust their lifestyle because, for example, if you are an alcoholic abuser, then you have high risk of bleeding if the patient know that if I drink a lot of alcohol, I will increase the bleeding risk. Then the patient will willing to quit drinking.
And, the whole system have Peer-reviewed double check to make sure that every pharmacy in the service is adherence with the standard and with the service SOP. So, when you want to create a SOP in your service, I think IT support is very important because it is almost impossible for pharmacists to see through page of page SOP and memorize by their heart and not making any mistakes. So, if they have the system to help them to go through step by step, and they will go through the SOP very well.

Wung explains the flowchart depicting the process of the whole treatment course. She later explains the standardized procedure of services at the anticoagulation clinic.

Key concepts

After enrollment in the anticoagulation clinic, patients receive their initial face-to-face consultation session. They can choose to have follow-ups in person or over the phone.

If the patient is INR unstable, experiences adverse drug reactions, or is hospitalized for warfarin-related reasons. The pharmacists will suggest to the doctors that the patient return clinic. If the patient is hospitalized, pharmacists will perform bed site care and discuss with the medical team for further treatment.

Follow-ups continue for 12 months, before determining if the patient should continue treatment or return to the doctor. There will be 2 additional follow-ups over the phone. If the patient returns to the clinic 6 months after case closure, they will enroll as an initial referral.

Service SOP:

There is an SOP for a patient interview, professional adjustment. pharmacy note and personal training etc.

Service SOP and standardized pharmacy notes. The pharmacists go through a list of standardized questions and the system will generate standardized pharmacy SOAP notes.

The system also auto-imports lab data and calculates key parameters like TTR% and CHA2DS2 scores during the interview. These results help to convince patients to cooperate with treatment.

Peer-reviews. Each case is peer-reviewed to make sure the service adheres to the standardized service SOP.

IT support is important as it is impossible for pharmacists to remember all the procedures and always make the right moves.

Share and learn:

  • Are services at the pharmacist clinic you work at/visited standardized?
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Good Pharmacy Practice: Introduction to Clinical Pharmacy Services

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