Understanding the essence of a "drug-refill" case
This post is for IMGs who have never worked or observed in the US, and wonder what's the big deal about spending 15 minutes on re-writing a patients prescription :-)
In contrast to some countries like India, most medications in the US CANNOT be bought "Over The Counter", i.e. they need a doctor's prescription. e.g. Antibiotics, Anti-hypertensives, Anti-Diabetics, etc. Now, for chronic conditions like diabetes & hypertension, the patients are usually given a prescription for 3 months (more or less depending on the docs discretion). Once the pills are exhausted, the patient comes back to see the doc to get a 'refill' (The physician may even authorize
a few more refills at the time of prescribing). You will begin to see that the beauty of having drugs "prescription-only" for chronic condition instead of having them over the counter, is that it becomes a mechanism which ensures that the patient visits the doctor regularly and gets a routine checkup.
So bear in your minds that a drug refill case is essentially a followup case to assess patients condition, complications and see if drug changes are needed.
Here's a protocol for specific data-collection on a drug-refill case:
1. How long ago was condition diagnosed ?
2. What medications is the patient on, if not provided in the case and
dosing - (SP should tell you names)
3. Next comes treatment compliance - if not taking regularly, why not ?
e.g. if the complaint is too many pills, you could counsel later about combination pills. Counsel also on need for compliance if poor compliance
4. Then drug side-effects: e.g. Dry cough for ACE-inhibitors. Counsel / reassure if side-effects present
5. How has his disease control been ? e.g. "So how have your sugars been running" for Diabetes or "What do you your blood pressure numbers read these days?" for Hypertension. Again counsel here if not checking sugars/pressures regularly
6. Next, ask go over symptoms typical for the condition.
e.g. polyuria, nocturia, polydipsia, polyphagia for diabetes
7. Then possible disease complications.
e.g. Numbness, Tingling, Visual Disturbances, Leg Edema, Foot ulcers for diabetes
8. Next, ask about routing followup labs
e. g. Routine fasting sugars, HbA1C, Urinanalysis, Lipid profile for diabetics done recently ? Remember values ?. If not done recently or records not available, then : "Lets get them done today" and you will list these on the investigations list on your patient note
9. "Any Other health complaints today" ?
- Then, quickly run through to the rest of the stuff on "PAM HUG FOSS"
Physical Exam: Proceed next to a general physical Exam and any specific exam for the condition in question (e.g. include ophthalmoscopy and foot exam for diabetics).
Counseling: Include relevant counseling points as mentioned above
Patient Note: On the patient note, briefly mention the data-collection points mentioned above, exam findings. On "Differential diagnoses" - start with the condition patient taking medications for, then enlist side-effects if any and then other complaints. On Management/Investigations - enlist the followup labs needed for the condition or any other that are warranted by patients complaints / side-effects.
Possible challenge question:
"Hey doc, will you be changing my medications today?"
Answer: I will have to assess your disease control after looking at the results of lab tests, I shall have my nurse convey the results to you and if we need to change anything.
This post is for IMGs who have never worked or observed in the US, and wonder what's the big deal about spending 15 minutes on re-writing a patients prescription :-)
In contrast to some countries like India, most medications in the US CANNOT be bought "Over The Counter", i.e. they need a doctor's prescription. e.g. Antibiotics, Anti-hypertensives, Anti-Diabetics, etc. Now, for chronic conditions like diabetes & hypertension, the patients are usually given a prescription for 3 months (more or less depending on the docs discretion). Once the pills are exhausted, the patient comes back to see the doc to get a 'refill' (The physician may even authorize
a few more refills at the time of prescribing). You will begin to see that the beauty of having drugs "prescription-only" for chronic condition instead of having them over the counter, is that it becomes a mechanism which ensures that the patient visits the doctor regularly and gets a routine checkup.So bear in your minds that a drug refill case is essentially a followup case to assess patients condition, complications and see if drug changes are needed.
Here's a protocol for specific data-collection on a drug-refill case:
1. How long ago was condition diagnosed ?
2. What medications is the patient on, if not provided in the case and
dosing - (SP should tell you names)
3. Next comes treatment compliance - if not taking regularly, why not ?
e.g. if the complaint is too many pills, you could counsel later about combination pills. Counsel also on need for compliance if poor compliance
4. Then drug side-effects: e.g. Dry cough for ACE-inhibitors. Counsel / reassure if side-effects present
5. How has his disease control been ? e.g. "So how have your sugars been running" for Diabetes or "What do you your blood pressure numbers read these days?" for Hypertension. Again counsel here if not checking sugars/pressures regularly
6. Next, ask go over symptoms typical for the condition.
e.g. polyuria, nocturia, polydipsia, polyphagia for diabetes
7. Then possible disease complications.
e.g. Numbness, Tingling, Visual Disturbances, Leg Edema, Foot ulcers for diabetes
8. Next, ask about routing followup labs
e. g. Routine fasting sugars, HbA1C, Urinanalysis, Lipid profile for diabetics done recently ? Remember values ?. If not done recently or records not available, then : "Lets get them done today" and you will list these on the investigations list on your patient note
9. "Any Other health complaints today" ?
- Then, quickly run through to the rest of the stuff on "PAM HUG FOSS"
Physical Exam: Proceed next to a general physical Exam and any specific exam for the condition in question (e.g. include ophthalmoscopy and foot exam for diabetics).
Counseling: Include relevant counseling points as mentioned above
Patient Note: On the patient note, briefly mention the data-collection points mentioned above, exam findings. On "Differential diagnoses" - start with the condition patient taking medications for, then enlist side-effects if any and then other complaints. On Management/Investigations - enlist the followup labs needed for the condition or any other that are warranted by patients complaints / side-effects.
Possible challenge question:
"Hey doc, will you be changing my medications today?"
Answer: I will have to assess your disease control after looking at the results of lab tests, I shall have my nurse convey the results to you and if we need to change anything.
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posted by Digitaldoc, MD at 8:11 PM
COMMENTS ON ""
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abhishek said ... (8:15 AM) :
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kunal said ... (3:54 PM) :
Post a commentGood information, thanks. I had been having this doubt for sometime now, didnt know whom to ask.
You have come to the right place Abhishek...
Kunal (on behalf of) DigitalDoc... without his permission ;)