Transcript v.2015-藥事執業技能

藥事執業技能：藥物相關問題之解決
Pharmacy Practice Skills: Drug-Related
Problems Solving
1
課程目的
• 了解 systematic clinical drug monitoring 的重
要性與目的
• 說明 SOAPing format 之組成及擷取藥事服務
所需資訊
• 了解 patient case presentation 之結構及順序
• 學習以 SOAPing format 建立完整的合理用藥
評估
• 藉案例學習，引導學生與指導老師充分互動
-重視討論的過程，而非結果
2
Systematic Clinical Drug Monitoring
的重要性
• The responsibility of a pharmacist to provide
services in a consistent and complete manner
• The complexity of a patient’s health problems
• The comprehensible communication among
health care professionals
3
The Purposes of Systematic Clinical
Drug Monitoring
• Determine that all of a patient’s drug therapy
is the most appropriate, most effective, safest,
and most convenient available.
• Identify any drug therapy problems (DTPs;
DRPs) and the goal of therapy.
• Identify any drug therapy problems (DTPs)
the patient is at risk of developing in the
future that is to say, any drug therapy
problems the pharmacist must help the patient
to prevent in the future
4
Pharmaceutical Care Process
5
Problem-Oriented Approach
• In 1964, Lawrence E Weed published the
problem-oriented approach to medical records,
patient care, and medical education.
• A systematic, disciplined approach to each
patient is used
• No important therapeutic considerations are
missed
6
Problem-Oriented Approach
• Two main components
– Complete problem list
• Physical
• Psychological
• Social/financial
– SOAP notes
• Logical thinking process
•連結理論和臨床, 並應用在醫療照顧
• One visit one SOAP
7
POMR
Problem Oriented Medical Record
• Dr. Lawrence Weed 提出將病歷制式化的構想
POMR= Problem List (第 x 項) + 各個 SOAP
– Problem 1+ SOAP 1
– Problem 2+ SOAP 2
– ……
• Modified SOAP
S
O
A (Problem 1, 2, …)
P (Problem 1, 2, …)
8
教學大綱
• 課程目標
• 病歷之基本組成
– Patient Case Presentation
• From database to plan
– 1. From data base to assessment (SOAP notes)
– 2. Assessment
– 3. From assessment to plan (Implentation)
• SOAPing format
– 案例說明
• Daily SOAP note
• Oral case presentation
9
教學內容重點
10
實際指導學生實習-案例討論
• 課程準備
– 安排課程表-學習過程
– 準備內容教材(挑選主題, 範例, 實例, workbook,
pharmacotherapy之參考依據)
• Disease Management Case Demo (ASHP’s PharmPrep 2001)
• Terry L. Schwinghammer pharmacotherapy Casebook 6th Ed.
• 課程分配
– 需多堂課 (10幾個小時)
– 漸進地介紹,才能完成
• 1. 上課解說 2小時
• 2. 範例說明 1小時
• 3. 學生實例演練 SOAPing format及討論
(2小時/次, 共 5-6次)
11
病歷之基本組成
12
病歷之基本組成
•
•
•
•
首頁
門診病歷
住院病歷
急診病歷
13
住院病歷
• 病歷摘要 (Discharge summary)
• 醫囑單 (一般 / 特殊 -TPN 及 C/T)
• TPR sheet
• Admission note (內科及外科 / 一般或各專科病歷用紙)
• Progress note (SOAP format)
• 會診記錄
• 治療申請單 (X-ray, Cath, RT)
• 檢驗報告 (Lab data)
• 監測觀察記錄單 (GCS, APACHE II scale)
• 輸入輸出記錄表 / 膀胱訓練記錄表
• 手術記錄
• 給藥記錄
• 護理評估表/ 護理記錄
• 出院準備服務 個案篩選表 / 收案病患記錄表
14
Medication Administration Record
(MAR)
• Routine or maitenance
– Antibiotics, anticonvulsants
• P.R.N.
–
–
–
–
–
Usually are listed at the end of the MAR
Fever (if >38.5℃)
Pain medication
Antiemetics
Sedative-hypnotic agents
• Stat (Statim, immediately)
– Administered once and not repeated unless recorded
– Given as soon as possible
– Prescribed in life-threatening or emergency situations
• One time order
– Given as soon as convenient and sometimes can be scheduled ahead of time
15
– C/T
住院日誌 Progress Note
• 目的
提醒每天病人發生了什麼事以及醫師目前的想法
• 精神-忠實記錄, 簡短(縮寫), 清晰易讀, 遵守常用習慣
• 重要性
– 對病患病程的演進，客觀的變化，醫師的判斷，臨床的
因應做一個重要的記錄
– 對病患而言，這是他的”傳記”，是他一生最重要的記
錄
– 對醫師而言，這是他訓練過程的”事證”，對自己的想
法與做法留下記錄;也是醫師間溝通的工具
– 對醫療而言，是醫療的重點記錄，是疾病處理的基本依
據，是繼續醫療的重要參考
– 對醫學而言，是人類醫學的重要資產，是醫學進步重要
文獻
16
• 格式-SOAP format
常用縮寫
•
•
•
•
一般身體評估(身體診察)
疾病診斷
藥品及其用法
檢查名稱
17
推薦讀物 (入門)
• 醫護專用縮寫辭典 (杜武志 主編)
– 取材範圍廣泛
• 醫, 牙, 藥, 護, 檢驗, 管理
• 疾病診斷, 理學檢查, 名稱, 病歷用語
• 台大內科住院醫師醫療手冊 (楊汾池 總編)
– 一般內科訓練 (primary care training)
– 綜論 (醫療實務要點, 各病房特殊檢查及術後照顧)
– 各論 (CV, GI, Nephro, Chest, Endo, Neuro, Rheuma,
ID, Hema, Oncology)
• The Washington Manual of Medical Therapeutics 31ed.
• Clinical skills for pharmacists, A patient-focused approach.
2nd Ed. Karen J. Tietze, Mosby
18
Patient Case Presentation
The accepted tool for documenting and communicating
patient information (suggested by Tietze, K.J.)
19
Components of the Patient Case Presentation
• General information
• Chief complaint (CC)
• History of present illness
(HPI)
• Past medical history (PMH)
Medication history (MedHx)
• Family history (FH)
• Social history (SH)
• Review of systems (ROS)
• Physical examination (PE)
• Pertinent positive and
negative laboratory and
diagnostic test results (Labs)
• P’t problem list and initial
plans
• P’t progress
• Discharge data
– Final diagnosis
– Discharge medications
• Plans for follow-up
20
Suggested Sequence for Presentation of Information
General information (Gen)
↓
Chief complaint (CC)
↓
History of present illness (HPI)
↓
Past medical history (PMH)
↓
Social history (SH)
↓
Family history (FH)
↓
Medication history (MedHx)
↓
↓
Review of systems (ROS)
↓
Physical examination (PE)
↓
Laboratory and diagnostic test
results (Lab)
↓
Problem list and initial plans
(SOAP format)
↓
P’t progress to date
(SOAP format)
21
From database to plan
Steps of Systematic Clinical Drug Monitoring
(suggested by Shao C, Chiang, Pharm.D., R.Ph.)
22
Problem Conversion
Medical problems (Dx)
Medication problems
(Drug therapy problems )
23
From Database to Plan
• 1.From data base to assessment
– SOAP notes
• 2.Assessment
• 3.From assessment to plan (Implentation)
– Therapeutics planning-pharmacist
• Diagnostic
• Therapeutic (Prescription)
• Educational (p’t)
– Monitoring
24
1.From data base to
assessment (SOAP notes)
At admission (new p’t)
25
Database
CC
HPI
PMH
FH
SH
Med Hx
Compliance
Allergies
ROS
PE
Lab tests
X-ray
Scans
Procedure
SOAP notes
SOAPing
Problem list
numbered
acuity/priority
Resolved / inactive
SOAP notes
Implementation of plan
diagnostic
therapeutic
educational (p’t)
Follow-up of progress
26
2. Assessment
At admission (new p’t)
27
Interpret the Findings in Terms of the
Probable Process
• Pathological process
– Congenital / Inflammatory
– Immunological / Neoplastic
– Metabolic / Nutritional
– Degenerative / Vascular
– Traumatic / Toxic
• Pathophysiological
• Psychopathophysiological
• Drug-related
28
Make One or More Hypotheses about the
Nature of the Patient’s Problem
• Select the most specific and central findings around
which to construct your hypothesis.
• Match your findings against all the conditions you
know that can produce them.
• Eliminate the diagnostic possibilities that fail to
explain the findings.
• Weigh the competing possibilities and select the most
likely diagnosis from among the conditions that
might be responsible for the patient’s findings
• Give special attention to potentially life-threatening
and treatable conditions
29
3.From assessment to plan
(Implentation)
Therapeutics planning
At admission (new p’t)
30
Components of Therapeutics
Planning
* Regimens- initial & alternative
31
The Planning Process
• Problem identification
– Identification of subjective and objective parameters
– Grouping of related parameters
– Assessment of the parameters and determination of specific
p’t problems
• Problem prioritization: Identify active and acute problems
• Selection of specific therapeutic regimens
– Creation of a list of therapeutic options
– Elimination of drugs from the list based on p’t-specific and
external factors
– Selection of dosage, route, and duration of therapy
– Identification of alternative therapeutic regimens
• Creation of a monitoring plan
– Monitoring and modification of the regimens as necessary 32
Common Subjective Parameters
Anxiety
Bloating
Blood-tinged sputum
Blurred vision
Breast tenderness
Chills
Cold intolerance
Confusion
Constipation
Cramps
Decreased appetite
Depression
Diarrhea
Difficulty concentrating
Dry skin
Dysuria
Fatigue
Flatulence
Headache
Heartburn
Heat intolerance
Impotence
Indigestion
Insomnia
Itching
Joint pain
Loss of appetite
Loss of libido
Muscle aches
Muscle weakness
Nasal congestion
Nasal itching
Nausea
Nervousness
Numbness
Pain
Palpitations
Pounding pulse
Rash
Seizures
Shortness of breath
Slurred speech
Sneezing
Sore throat
Syncope
Thirst
Tingling
Tinnitus
Tremor
Vertigo
Weakness
Wheezing
33
Common Objective Parameters
BH and BW
Vital signs
BT, BP, HR, RR
Blood chemistries
Na, K , Cl, CO2, Glu, Scr, AST, ALT, Bil, Ca, Mg, CHL, TG, Alk-P, LDH, UA, BUN
Blood gases
pH, Pco2, Pco2, HCO3Blood protein
Total protein, albumin, complements, immunoglobulins
Hematolog
Hb, Hct, MCV, MCH, MCHC, RBC, WBC DC
Urinalysis
Sp. gr, cellular content, protein
Cultures and sensitivites
Blood, urine, sputum, tissue
Serum blood concentrations
Specific organ system tests
PEFR, FEV1, FVC , FEV1/FVC, EF, T3, T4, TSH, Clcr
Miscellaneous
U/O, abd girth, no. of loose stools/day, I/O
34
Factors to Consider when Selecting a
Specific Therapeutic Regimen
• Patient-specific factors
– What regimens have effectively managed the problem in the
past？
– What regimens have not effectively managed the problem in the
past？
– How might other patient problems influence the proposed
regimen？
– How might the proposed regimen influence other patient
problems？
• External factors
– Current “state of the art” therapeutics
– Cost of the proposed therapv
– Formulary limitations
35
Guidelines for Altering Initial Drug Therapy
• If the regimen is ineffective, change the drug if the following are
true
– The patient received an adequate trial of the drug
– The patient received an adequate dosage of the drug
– The patient is compliant
• If the regimen is associated with life-threatening side effects,
discontinue the drug
• If the patient is not complying with regimen because of
unacceptable side effects, discontinue the drug
• If the patient has non-life-threatening side effects and is willing
to continue the drug,
– minimize the side effects by doing the following:
• Adjust the dosage of the drug
36
• Change the timing of the dose
3.From assessment to plan
(Implentation)
Monitoring
At admission (new p’t)
37
Patient-Focused Care Cycle
A Never-Ending Cycle
Data acquisition
and assessment
Patient
monitoring
Problem identification
and prioritization
Therapeutic
planning
38
The Process of Monitoring Therapeutic
Regimens
1. Set therapeutic goals
2. Determine patient- and drug-specific
monitoring parameters
3. Integrate the monitoring plan
4. Obtain data
5. Assess the response to therapy
6. Alter the therapeutic regimen if necessary
7. Repeat Step 1-6
39
Organization of Monitoring Parameters
(The Four-Square Method)
Subjective-Therapeutic
Subjective-Toxic
expected therapeutic outcome
indicating therapeutic failure
or harm
Objective-Therapeutic
Objective-Toxic
expected therapeutic outcome
indicating therapeutic failure
or harm
40
Steps of systematic clinical drug
monitoring at inpatient setting
Hospital stay (old p’t)
41
Hospital Stay
•
Daily SOAP note
–
–
–
•
Each problem has its own SOAP note.
The subjective and objective data should include
the values of drug monitoring parameters.
All problems should be assessed and planed,
unless the problem has been resolved
Daily drug monitoring
42
Real Practice Setting
• With time and practice, the process of
assessing patient therapy and prioritizing the
need to make an intervention becomes second
nature and does not require a concerted effort
to mentally check off each step after it has
been performed.
• Setting priority about which patients require
more in-depth intervention.
43
SOAPing format
44
SOAPing Format
• SOAPing
The process of identifying the subjective and objective data,
assessing the problem, and developing a specific therapeutic
and monitoring plan
• A formal organizationl structure
• Steps
–
–
–
–
Creation of a list of related subjective parameters
Creation of a list of related objective parameters
Assessment and documentation of the problem
Documentation of the therapeutic plan for addressing the
problem
45
Thinking Process Tips
•
•
•
•
•
•
Problem identification
Desired outcome
Therapeutic alternatives
Optimal plan
Outcome evaluation
Patient education
46
Problem List
Current medical problems
Goal of therapy
Measurable endpoint
47
SOAPing Format
USC School of Pharmacy Kathleen Besinque Pharm D, MS Ed.)
Subjective and Objective
Assessment
Plan
Problem
Current
Etiology (or risk Evaluate need for therapy; evaluate Recommended drug Goal and
(subjective
and
objective)
medication
factors)
current therapy (Evidence need for treatment, drug to
therapy evaluation)
be revised, further
test
Patient
monitoring
education
parameters (toxic
and therapeutic)
48
Current Drug-Therapy Problems
Subjective and Objective
Problem
(subjective and objective)
Current medication
S:
CC:
Pertinent medical Hx:(HPI / PMH)
ROS:
SH:
FH:
Allergies:
ADR:
Drugs
OTCs
Herbal
O:
(PE /Labs)
49
Current Drug-Therapy Problems
Assessment
Etiology
(or risk factors)
Evaluate need for therapy; evaluate current therapy (Evidence need for therapy
evaluation)
Drug therapy
problem 1
CPG1
Class of drugs
Drug therapy
problem 2
CPG2
Class of drugs
Drug therapy
problem 3
CGP3
Class of drugs
50
Current Drug-Therapy Problems
Plan
Recommended drug treatment,
drug to be revised, further test
Goal and monitoring Patient education
parameters (toxic and
therapeutic)
Recommend 1
Item of drugs
Goal 1
Therapeutic
Toxic
Education 1
Recommend 2
Item of drugs
Goal 2
Therapeutic
Toxic
Education 2
Recommend 3
Item of drugs
Goal 3
Therapeutic
Toxic
Education 3
51
Problem Conversion
Medical problems (Dx)
Medication problems
(Drug therapy problems)
52
教學時遭遇的困難與處理
53
教學時遭遇的困難與處理 (1)
• 藥師指導 clinical drug monitoring 及 case presentation 之技巧
有差異
– 參與醫院藥學實習指導師資認證訓練課程
• 閱讀病歷抓不到 (困難擷取)藥事服務所需資訊
– Medical problem (Dx)
Medication problems
(Drug therapy problems)
– 病歷上少有藥師的記錄或看到daily SOAP note
• 持續練習就能習慣
• 如何釣魚需由作中去領悟
54
教學時遭遇的困難與處理 (2)
• 教學過程多是由指導藥師來告訴答案
–藥師在藥事服務介入的時間多於學生
–報告時間的壓力
–學生常是事到臨頭才要做
–學生難於確認那麼多Drug therapy problems
• 臨床教學模式
–常是糾正學生的錯誤, 解釋處理Drug therapy problems的
原則
–已修過藥物治療學 / 臨床藥學課程者再實習
• 病案報告非 concurrent case
–藥師需作調劑工作
–藥師未全程參與病患照護
–難了解醫師對藥師意見的接受度及藥師建議的可行性
55
結論
• Problem oriented drug monitoring
• 有清晰的邏輯思考
• 可解決複雜的Drug therapy problems
•本課程是建立思考邏輯
•沒有絕對標準的答案
•引導學生/藥師的指導藥師-很重要
56
Case Example(案例說明)
Hypertension
57
課程目標(HTN)
• Establish goals for the treatment of HTN.
• Choose appropriate lifestyle modifications and anti-HTN
based on patient-specific characteristis and concurrent disease
states.
• Design appropriate monitoring plans for pts receiving antiHTN therapy, including laboratory parameters and time
intervals.
• Modify pharmacotherapeutic regimens for pts who experience
adverse events or do not have adequate BP reduction on an
initial regimen.
• Provide appropriate patient education for anti-HTN regimens.
58
Patient General Information (Gen)
病患基本資料
Patient name: 王先生
Chart no: xxxxxxxx
(Bed no: xxxx-x)
Address: 台南市信義路
Age: 79
Height: 175 cm
Sex: M
Marriage status: married
Weight: 95.4kg
Allergies: NKDA
Date of admission (DOA) : yy mm dd
59
Chief Complaint (CC)
病患主訴病情
• 王先生 is 79-yo male seen in the ED with
respiratory distress with severe dyspnea and
wheezing.
60
History of Present Illness (HPI)
發生現在疾病之病程
• 王先生 was coming home from the grocery store
when he became short of breath and wheezing
carrying in his groceries.
• He could only say a couple words between breaths.
His neighbor noticed him in distress and called 911.
• 王先生 experienced severe shortness of breath 6
months ago and was hospitalized for acute severe
asthma.
61
Past Medical History (PMH)
過去病史
• Diagnosis with asthma approximately 20 years ago,
rheumatoid arthritis about 5 years ago, and benign
prostatic hyperplasia last year.
• Patient using a herbal product to treat his benign
prostatic hyperplasia.
• Admitted to hospital 3 times in the past 2 years for
exacerbation of asthma.
• Previous office visit 5 weeks ago, documented a
blood pressure reading of 150/95 mmHg.
62
Social History (SH)
個人生活史
• Tobacco use: 1/2 pack/week
• Alcohol use: Six pack per week
• Caffeine use: 2 Cups of coffee every morning
63
Family History (FH)
家族病史
• Mother died of an MI at age 68.
• Father died of lung cancer at age 75.
64
Medication Record (Prescription and
OTC) (MedHx)用藥史
•
•
•
•
•
•
Furosemide 40 mg po q AM
Albuterol inhaler 2 puffs qid prn
Beclomethasone inhaler 1 puff qid
Ibuprofen 800 mg po tid
Herbal product with licorice po qd
Acetaminophen po prn
65
Review of Systems (ROS)
現有疾病或問題 (HPI 除外)
• Wheezing and coughing
66
Physical Examination (PE)
身體診察
• VS:
–
–
–
–
–
–
–
BP 160/100 mmHg
HR 120 beats/min
RR 31 rpm
T 38.5℃
Ht 175 cm
BW 95.4 kg
BMI 31.2 (95.4/1.75x1.75)
• CHEST: Expiratory wheezes
67
Laboratory and Diagnostic Tests (Labs)
檢驗數據及檢查報告
Potassium
3.8 mEq/L
FBG
100 mg/dL
RBC
4.7 cells/mm3
PH
7.40
Sodium
145 mEq/L
Total cholesterol
200 mg/dL
Serum creatinine
1 mg/dL
Hgb 15 g/dL
HDL
35 mg/dL
Hct 44%
PaO2
55 mmHg
PaCO2
40 mmHg
68
Diagnosis
診斷
• Primary:
1)Asthma
2)Hypertension
• Secondary:
1)Benign prostatic hyperplasia
2)Rheumatoid arthritis
• Problem list
69
Problem List
Current medical
problems
Primary:
1)Asthma
2)Hypertension
Secondary:
1)BPH
2)RA
Goal of therapy
Symptom control
Prevent asthma episodes or
attacks
Prevent CHD, Stroke and
Nephropathy
Measurable endpoint
PEFR
No DOE, SOB, PND
BP
Symptom control
DRE (digital rectal exam)
UFR (urine flow rate)
Improve QOL
Arrest or retard disease
progress
Swollen & tender joints
RF, ESR, ANA, CBC
X-Ray
70
Current Drug-Therapy Problems
Subjective and Objective
Problem
(subjective and objective)
Current medication
S:
Pertinent medical Hx:Asthma x 20 yrs; RA x 5 yrs; BPH x 1yr
ago; HTN x 5wks
ROS: respiratory distress with severe dyspnea ; wheezing and
coughing
Tobacco use: 0.5 pack/week ; alcohol use: 6 pack / week ;
caffeine use: 2 cups of coffee every morning
Use a herbal product to treat his BPH
Furosemide 40 mg po q AM
Albuterol inhaler 2 puffs qid prn
Beclomethasone inhaler 1 puff qid
Ibuprofen 800 mg po tid
Herbal product with licorice po qd
Acetaminophen po prn
O:
175cm , 95.4kg HR:120 BP:160/100 RR:31 T38.5℃
Expiratory wheezes
PH 7.40; PaO2 55; PaCO2 40
Admitted to hospital 3 times/past 2 yrs for AE of asthma
BP 150/95 mmHg previous office visit 5 wks ago
71
Current Drug-Therapy Problems
Assessment
Etiology
(or risk factors)
Evaluate need for therapy; evaluate current therapy (Evidence need for therapy
evaluation)
AE of asthma
Primary therapies for AE (most safely undertaken in a hospital or hospitalbased ER)
Repetitive administration of rapid-acting inhaled β2-agonist
Early introduction of systemic glucocorticosteroids
Oxygen supplementation
Closely monitor response to treatment with serial measures of lung function
Inadequate response
to treatment for HTN
D/C herbal product with licorice ( has been shown to have an aldosterone-like
action)
Both ibuprofen and licorice can cause an inadequate response to HTN therapy
If BP remains elevated, the clinician should consider initiating anα-blocker
Inadequate BPH
treatment
The preferred therapy for this pt may be α-blockers (the favorable effects on
prostatism and dyslipidemia-decrease LDL-C and increase HDL-C
Postural hypotension is commonly experienced withα-1 blockers because of
the direct action
The “first-dose phenomenon ” is characterized by transient dizziness,faintness,
72
palpitations, and syncopy occurring within 3 hrs of the first dose.
Current Drug-Therapy Problems
Plan
Recommended drug treatment,
drug to be revised, further test
Goal and monitoring Patient education
parameters (toxic and
therapeutic)
IV methylprednisolone 60-80 mg
or Hydrocortisone 300-400 mg ;
or oral prednisolone 0.5-1 mg/kg
for 7-10 days
Decrease symptom
PEFR
(GINA 2004)
Report any  in SOB, DOE, PND
Techniques in use of medications
Smoking cessation
D/C herbal product with licorice
BP check daily
BP in 1wk < 140/ 90
(JNC VIII)
Teach pt how to self measurement of BP
Remind pt that home measurement
device should be checked regularly
for accuracy
Lifestyle modification recommendations
(5 modifications)
Usual dose :
Prazosin 2-30 mg ,bid-tid
Terazosin 1-20 mg ,qd-bid
Doxazosin 1-16mg ,qd
(first dose at hs)
Decrease symptom
(bladder outlet
obstruction, postvoid
residual urine
volume, reverse urinary
retention / RI
May be avoided by having the pt take the
first dose and/or the first increase in
dose at bedtime
73
尾端 Un Clos (A Close)-塞尚 Cezanne 1890
謝謝聆聽 敬請指教
74
時間分配
•
•
9:20 ~ 10:50 分組討論與演練
10:50 ~ 12:00 各組心得分享
–
第一組報告 10:50 – 11:00 ~ Type 2 DM--initiate OADs in a
newly diagnosed DM patients
–
第二組報告 11:00 – 11:10 ~ Hypertension--inappropriate
drug of choice and inadequate BP control for HTN
–
第三組報告 11:10 – 11:20 ~ Hyperlipidemia--initiate lipid
lowing agents for a patient with high CV risks
–
第四組報告 11:20 – 11:30 ~ Obesity, metabolic syndrome-pharmacotherapy of obesity and metabolic syndrome
–
–
–
第五組報告 11:30 – 11:40 ~ 案例各問題補充報告
第六組報告 11:40 – 11:50 ~ SOAP格式心得報告
11:50 ~ 12:00 輔導員分享
其他注意事項
1.雖然有主題報告，仍有學員不熟悉SOAP，有時需解釋並分
辨哪些屬於"S"、哪些屬於"O"、哪些屬於"A"、哪些屬於"P"
，請在課程報告中詳述佐以實例說明。
2.學員大部分都很怕講錯，一定要讓學員了解，課程是要訓
練他們熟悉寫SOAP的思考模式和流程，所以上課時不要太
在意所提出的"PLAN"對不對，而輔導員或主持人在講評時
也儘量針對SOAP本身就好（除非真的建議的內容太離譜啦
~）。
3.雖然練習的個案資料內容很豐富，但是要提醒學員在實際
臨床時，有些資料不是光靠病歷閱讀來取得，尤其是針對
藥物的部分（過去用藥史，有病史為何未用藥？...等等）。
4.善用手冊的SOAP表單，更能掌控A、P呈現的重點。
註：請參考輔導員帶領小組討論的技巧與注意事項