Nonprescription Counseling Basics Pharmacy Practice
The Counseling Process Opening Discussion Discussion to Gather Information and Identify problems Discussion to prevent and resolve problems Providing appropriate information Closing discussion Follow-up discussion
Opening Discussion Develop a helping relationship Introductions (RPh and patient) Explain purpose and time involved
The SOAP Note Subjective Objective Assessment Plan
Subjective The information the patient gives you Gathering Information: Communication techniques Tell me more about it Nonverbals, empathy Open ended questions Who, what, where, when, why, how Using “summary” to verify understanding (both RPh & pt.)
Subjective: Chief complaint Symptom evaluation Location Timing Quality Associated symptoms Severity Setting/history Modifying factors Meaning to patient
Subjective: Patient History Medical history: conditions & allergies Medication use: Rx and OTC Social :EtOH, tobacco, caffeine, rec. drugs Previous treatment, experience
Objective Physical data that you can observe or measure Patient appearance Vital Signs Blood pressure Heart rate Respiratory rate Focus of P2 lab year
Assessment Identifying the problem Differential: What could it be? Using subjective and objective information Explain why you reached your conclusion Includes therapeutic goals and alternatives
Assessment: To refer or not? Age Nature and severity of symptoms Duration of symptoms Other existing conditions and medications Pregnancy Your confidence level
Plan Name of the medication Purpose Directions Desired effects Unwanted effects and management Precautions Time frame for effectiveness
Plan Nonpharmacological recommendations Symptoms Conditions Follow-up
Closing Obtain feedback Verify understanding Written information Documentation S.O.A.P. notes
Follow-up Timing Phone call or visit