PATIENT COUNSELING

DR. FITA RAHMAWATI, Sp.FRS, Apt

Department of Pharmacology and Clinical Pharmacy

Faculty of Pharmacy
Universitas Gadjah Mada
Yogyakarta

Email : malihahanun@yahoo.com
 INTRODUCTION
Safe and effective drug therapy depends
on patients being well informed about
their medication.

GOOD DRUGS
can be
BADLY USED
 To Chew or not to Chew
Pasien 83 thn, mendapat resep :

• CARDIZEM CD (DILTIAZEM LEPAS LAMBAT),

utk Blood Pressure
• Kapsulnya besar.
• Kapsul dikunyah.

• kejadian berulang.
• Pasien meninggal 3 minggu kemudian.
What pharmacist could be done to
prevent the event?
 Kalau saja…..
• Farmasis menyempatkan mereview
resep, dan konseling
–Ukuran kapsul yang besar
–Konseling : jangan dibelah, dikunyah

Tidak melakukan konseling

Salah dalam memberikan konseling
 INTRODUCTION
The patient do not get enough information about use of
their medication (how, when, how long to take the
medication, what to do if side effects occur or a dose
is missed

Lack of information may lead to

• The therapeutic failure,
• Adverse effects,
• Additional expenditure on investigations and
treatment or
• Hospitalisation.
 The NATIONAL BURDEN of
NONADHERENCE (US)
• Research has proven that medication adherence ranges
from 20% to 70% for chronic conditions

• Kurang lebih 125.000 kematian pertahun karena

nonadherence, atau dua kali jumlah kematian akibat
kecelakaan mobil

• Hampir 11% pasien rawat inap dan 40% pasien sakit di

panti jompo, adalah akibat nonadherence

• Biaya langsung maupun tidak langsung akibat

nonadherence mencapai $100 milyard per tahun di
USA
 DEFINITION
• Patient counselling refers to the process of
providing information, advice and assistance
to help patients use their medications
appropriately.

• According to USP, medication counseling is

an approach that focuses on enhancing the
problem solving skills of the patients for the
purpose of improving or maintaining the
quality of health and quality of life.
 PHARMACEUTICAL CARE
PROCESS
PATIENT MED PROFILE

ASSESSMENT
PHARMACEUTICAL CARE
PROCESS

DRP

PHYCICIAN COUNSELING
 DIAGRAM LANGKAH KONSELING

PASIEN YANG DIPILIH

PERKENALAN & PENJELASAN

TUJUAN KONSELING

Obat Bebas RESEP RAWAT JALAN RESEP RAWAT INAP

DITANGANI OLEH DISARANKAN KE RESEP

APOTEKER DOKTER BARU ULANG AWAL PULANG

OBAT NON OBAT PRIME QUESTIONS SHOW & TELL

TECHNIQUES TECHNIQUES

Membongkar EXPLORE & IDENTIFIKASI

‘fenomena gunung es’ MASALAH MINUM OBAT

KOMUNIKASI DENGAN EMPATI & RESPONS

(ACTIVE LISTENING)

VERIFIKASI AKHIR

KEMBANGKAN & FOLLOW UP

 The Pharmacist should Prepare:

• COUNSELING METHODS
– Three Prime Questions
– Show and Tell
• CLINICAL KNOWLEDGE
– Patophysiology
– Pharmacotherapy
– Evidence Based Medicine etc
• GOOD COMMUNICATION SKILL
• PRODUCT KNOWLEDGE
• EXPERIENCE
• TOOLS
 The Prime Questions
• What did your doctor tell you this medication
was for?
• How did your doctor tell you to take this
medication?
• What did your doctor tell you to expect?
 Refills
• Show and tell
– Place the pill in the lid and ask the patient:
– So, what are you using this medication for?
– And how do you take it?
– And are you having any problems?
 Counseling
Session
Introduction
Greeting to
Patient
Verification for
Identity of Patient

Pharmacological Non-
approaches pharmacological
approaches
• The information is usually given verbally, but may be
supplemented with written materials .

• During counseling, the pharmacist should assess the

patients understandings about his or her illness and
treatment, and provide individualized advise and
information which will assist the patient to take their
medication in the most safe and effective manner.

• To provide accurate advice and information, the

pharmacist should be familiar with the pathophysiology
and therapeutics of the patients disease.
• Good communication skills are needed to gain the
patients confidence and to help motivate the patient to
adhere to the recommended regimen.
 OBJECTIVES OF P.C
1) Better patient understanding of their illness and the
role of medication in its treatment.
2) improve medication adherence
3) more effective drug treatment
4) reduced incidence of adverse effects and
unnecessary healthcare costs.
5) improved quality of life for the patient.
6) better coping strategies to deal with medication
related adverse effects.
7) Improved professional rapport between the patient
and the pharmacist.
 STEPS DURING PATIENT COUNSELLING

1) Preparing for the session.

2) Opening of the session/Introduction
3) Counselling content
-Prime question
- Show and tell
4) Final verification & Closing the session.
5) Follow up
 INSTRUMENT
• Ruang/tempat tempat komunikasi nyaman , privacy
agar tercapai komunikasi yang optimal. Hendaknya:
- kurangi barier fisik semaksimal mungkin
- pusatkan perhatian ke pasien
- condongkan badan ke arah pasien
- kontak mata
- hindarkan interupsi
- jangan terlalu keras supaya tidak terdengar orang lain

• Form pengobatan mandiri

• Form konseling
• Pustaka, Internet
• Alat peraga konseling
 Process Steps
1)Establish caring relationships with patients
• Introduce yourself (as a pharmacist )
• Greet the patient
• Patient veryfication
• Explain your purpose
• Ask the patient’s permission to counsel

• Know your audience

– Educational level: tailor talk for understanding
– Use appropriate language
– Religious or ethnic beliefs
2) Assess the patient’s knowledge about his or her
health problems and medications, physical and
mental capability to use the medications
appropriately and attitude toward the health
problems and medications.

• Ask open ended questions about each

medication’s purpose and what the patient
expects, and ask the patient to describe or show
how he or she will use the medication.

• They should also be asked to describe any

problems, concerns, or uncertainties they are
experiencing with their medications.
Open vs. Closed Ended Questions
• Open ended provide more information
– Tell me more about the symptoms you are
having…

• Closed provide only limited information

– Did your doctor tell you to take 1 tablet daily?
– Do you know how long you will need to take
this medication?
3) Provide information orally and use visual aids or
demonstrations to fill patients’ gaps in knowledge
and understanding.

• Show the patient patients: the colors, sizes,

shapes, and markings on oral solids.
• For oral liquids, show patients the dosage marks
on measuring devices.

• Demonstrate the assembly and use of

administration devices such as nasal and oral
inhalers.

• As a supplement to face-to-face oral

communication, provide written handouts to help
the patient recall the information.
4) If a patient is experiencing problems with the
medications, gather appropriate data and assess
the problems.
• Then adjust the pharmacotherapeutic regimens
according to protocols or notify the prescribers.

5) Verify patients’ knowledge and understanding of

medication use. Ask patients to describe or show
how they will use their medications and identify their
effects.

• Observe patients’ medication-use capability and

accuracy and attitudes toward following their
pharmacotherapeutic regimens and monitoring plans.
Assess Patient’s Understanding
“Just to make sure I did not leave
anything out, could you tell me…[examples]

– What is the medication used for?”

– When are you going to take the
medication?”
– What side effects might you experience?”
– What will you do if that occurs?”
– What will you do if you miss a dose?”

29
 Counselling Content
1. The medication’s trade name, generic name, common synonym,
or other descriptive name(s) and, when appropriate, its therapeutic
class and efficacy.
2. The medication’s use and expected benefits and action. This
may include whether the medication is intended to cure a disease,
eliminate or reduce symptoms, arrest or slow the disease process,
or prevent the disease or a symptom.
3. The medication’s expected onset of action and what to do if the
action does not occur.
4. The medication’s route, dosage form, dosage, and
administration schedule (including duration of therapy).
5. Directions for preparing and using or administering the
medication. This may include adaptation to fit patients’ lifestyles or
work environments.
6. Action to be taken in case of a missed dose.

7. Precautions to be observed during the medication’s use

or administration and the medication’s potential risks in
relation to benefits.

8. Potential common and severe adverse effects that may

occur, actions to prevent or minimize their occurrence, and
actions to take if they occur, including notifying the prescriber,
pharmacist, or other health care provider.

9. Techniques for self-monitoring of the pharmacotherapy.

10. Potential drug–drug (including nonprescription),

drug–food, and drug–disease interactions or
contraindications.
11. The medication’s relationships to radiologic and
laboratory procedures (e.g., timing of doses and
potential interferences with interpretation of results).

12. Prescription refill authorizations and the process for

obtaining refills.

13. Instructions for 24-hour access to a pharmacist.

14. Proper storage of the medication.

15. Proper disposal of contaminated or discontinued

medications and used administration devices.

16. Any other information unique to an individual patient or

medication.
 Documentation of Counseling
Session
• When counseling is completed
– Write note or use counseling sticker in
progress note.
– Include assessment of patient and/or care
giver understanding.

33
 COMMUNICATION

The communication process uses

1) VERBAL COMMUNICATION SKILLS :- like

TONE VOLUME SPEED

LANGUAGE

2) NON-VERBAL COMMUNICATION SKILLS:- like

BODY LANGUAGE PROXIMITY EYE CONTACT FACIAL EXPRESSION

BARRIERS TO EFFECTIVE COMMUNICATION

• PHYSICAL,
Environmental barriers such as a lack of
privacy, noise, furniture,

• PSYCHOLOGICAL,
Semantics, effective patient communication
requires the use of words that are carefully
chosen.
Perception
Negative attitude
 Environment
• Education and counseling are most effective when
conducted in a room or space that ensures privacy and
opportunity to engage in confidential communication.
• If such an isolated space is not available, a common area
can be restructured to maximize visual and auditory
privacy from other patients or staff.
• Patients, should have easy access and seating.
• The design and placement of desks and counters should
minimize barriers to communication.
• The environment should be equipped with appropriate
learning aids, e.g., graphics, anatomical models,
medication administration devices, memory aids, written
material, and audiovisual resources.
BARRIERS TO EFFECTIVE COMMUNICATION

• ADMINISTRATIVE
Administrative barriers such as management may view
the lack of money compensated for communication as a
reason not to communicate.

• TIME CONFLICT.
Time limits are very common when it comes to
pharmacists and patients. Time restraints are often
excuses not to counsel, though it often does not take
very long.
 Other barriers to counseling:
– Disease state: dementia, stroke
– Language: verify primary language
– Hearing/vision problems
– Educational level (reading ability)
– Patient motivation: disinterest in learning
– Lack of pharmacist training

38
 Minimize Barriers:
Effective Communication Skills
• Be specific
– Name of medication (brand/generic), dose, dosage
form, schedule
– List precautions: e.g., use sunscreen, avoid milk
– How to administer (Sub-Q, PO, IM etc.)
– Special directions and precautions
• Be selective
– Cover major / common side effects, drug interactions
– Cover patient specific indication
– Emphasize benefits of medication
– Duration of therapy
– Provide written information
39
 Minimize Barriers: Effective
Communication Skills
• Be sensitive/empathetic
– Listen to the patient
– Speak distinctly and clearly
– Return later if patient indisposed, not alert,
distracted, has visitors etc.

40
 Example: Warfarin Counseling
• DO • DON’T
– Address patients – Address patients by
formally their first names
– Ask what the patient – Assume the patient
knows about warfarin knows all or nothing
or Coumadin® about the drug

41
 Example: Warfarin Counseling
• DO • DON’T
– Explain that warfarin is – Explain that warfarin is
used to slow the blood an anticoagulant
clotting process to – Explain that warfarin
prevent unwanted works by inhibiting the
blood clots vitamin K dependent
– Ask patients to call clotting factors and
their doctor if they that it is an emergency
notice bleeding that situation if they see
they don’t normally any blood
have

42
 Example: Warfarin Counseling
• DO • DON’T
– Identify the specific – List every reason
reason the patient is anyone might be on
taking it and how long warfarin
they might be
expected to take it

43
 Example: Warfarin Counseling
• DO • DON’T
– Explain the signs and – Give the patient the
symptoms of bleeding impression that they
such as bloody nose, are going to bleed to
blood in the urine, a death
stool that changes
color or darkens,
bruises that never go
away or increase in
size

44
 Example: Warfarin Counseling
• DO • DON’T
– Ask the patient to tell
all their doctor/ dentist
etc. all the medications
they are taking
including
nonprescription ones
(e.g., pain
medications, vitamins,
herbal products)
– Assume the patient
realizes the need to
notify all health care
providers concerning
all the medications
they are on; OTCs are
often not considered
medications
45
 Example: Warfarin Counseling
• DO • DON’T
– Ask the patient to avoid – Indicate that the only good
taking OTC pain pain medications are those
medications such as
found on prescription
aspirin, unless they have
discussed it first with their
physician
– Recommend Tylenol® as
the OTC pain reliever of
choice with their
physician’s knowledge as
well

46
 Example: Warfarin Counseling
• DO • DON’T
– Tell the patient what to – Tell the patient to
do if he or she forgets double up on their next
a dose dose if they miss one
– Ask the patient to
inform their physician
or anticoagulation
clinic if a dose is
missed

47
 Example: Warfarin Counseling
• DO • DON’T
– Stress the need for – Minimize the
follow-up importance of
appointments and follow-up by an
blood draws anticoagulation
– Indicate that it is clinic or a physician
normal for doses to
change from time
to time

48
 Example: Warfarin Counseling
• DO • DON’T
– Ask the patient to eat – Limit or forbid the
a constant and patient to eat salads or
moderate diet where vegetables.
they eat vegetables
and salads in a
consistent manner and
neither over do nor
stop eating what they
normally eat

49
 Example: Warfarin Counseling
• DO • DON’T
– Summarize key points
covered – Assume the patient
– Ask if the patient has any has no final questions
other questions – Assume the patient
– Ascertain that the patient
understands the
has understood all you
information have discussed
– Thank the patient and – Forget to leave a note
leave written information
in the chart
– Document as required

50
 Who and When to counsel
• Ideally, the pharmacist counsels patients on all new and
refill prescriptions.
• If the pharmacist cannot counsel to this extent, it should
be defined which patient types, or which medications
pharmacists will routinely counsel patients.
• This will vary depending on the pharmacy clientele, Exp:
- Patients receiving more than a specified number of medications
- Patients known to have visual, hearing or literacy problems
- Paediatric patients
- - Patients on anticoagulants
Modified Morisky Scale (MMS)
THANK YOU