How to work-up a patient

Tips from an inpatient pharmacist for students, residents, and practicing pharmacists to see one strategy to work up a patient. This post is also beneficial for medical students/residents/practitioners/nurses to understand how pharmacy looks at a patient chart.

The essence of practicing medicine is patient care. To take care of a patient, we need to be able to efficiently and thoroughly review a patient chart. If you are in pharmacy school or if you work in a clinical pharmacy position, you are familiar with how important it is to work up a patient.

Everyone will have their own preferred way to navigate a patient chart. For some, they like to look at the medications first. Others like to go straight to the most recent notes or H&P to understand why the patient is admitted and what their current status is.

As an inpatient pharmacist, you may be scheduled on various shifts throughout the week. For example, I sometimes have a few days on cardiology, a day in the emergency department, and a day in transplant all in the same week. It makes patient continuity quite difficult. However, with a structured way to work-up your patients, you can orient yourself to the new list of patients rather efficiently. This will help prepare you for rounds, phone calls from nurses/providers, and discharge questions.

The template below is my personal preference, but my workup can vary day-to-day and patient-to-patient. If I am entering a patient’s chart to review gentamicin levels, I will review their profile much differently than if I were reviewing a phenytoin level.

Below are two other references for patient workup strategies for your convenience.

Presenting+a+Patient+Guide_2024.docx

Interior Health Pharmacy Residency Program http://www.ihpharmacy.com/patient-care-resources/

Presenting+a+Patient+Guide_2024.docx.pdf

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My outline of how to review a new patient’s chart:

Step	Action	Reasoning
1	Review handoffs from previous pharmacists or colleagues	This will give me an introduction into pharmacy pertinent tasks and may help guide my chart review
2	Review medications	We are pharmacists: medications are our job! From the medications, I can piece together what may be going on with the patient, start to form my own questions, and do a quick check of dosing and interactions while I orient myself to the profile
3	Review chief complaint and most recent provider notes May review History & Physical (H&P)	To understand why the patient is here and what acute disease/problem we are treating. I usually note the first 2 or 3 problems The H&P is especially helpful for patients in the ED who will be admitted or for patients who have been in the hospital for less than 48 hours
4	Review medications again	Once I know why the patient is here and what problems we are concerned with/treating, I go and look for appropriate medication therapy based on guideline recommendations Example: CAD --> statin, beta blocker, ACE-I/ARB, aspirin
5	Review recent labs usually in this order: - Complete Metabolic Panel (CMP) + LFTs - Complete Blood Count (CBC) - Vitals/Hemodynamics - Glucose control and diet If the patient is a solid organ transplant recipient - Check trough levels of immunosuppressants	CMP+LFTs: to assess for any electrolytes that need to be repleted or any abnormalities that may be due to a medication currently ordered CBC: to ensure values are normal or stable Vitals: (especially if currently infected or a cardiac/renal patient) to assess if more/less treatment is needed and assess for sinus rhythm Glucose/diet: to understand which route medications can be given and if adjustments to insulin regimens are warranted *While checking these values in EPIC, my navigators allow me to see which medications have been given in relation to the lab values. If the patient is hypertensive, I can see if a dose of losartan was recently given or not
6	Review any recently ordered labs that may be pending (mainly microbiology!)	To see what labs have resulted, understand what the team is concerned about, and help leave a handoff for future pharmacists if any labs are still in process
7	Review medications again for renal adjustments	To ensure every medication is dosed appropriately based on current renal function
8	Check for venous thromboembolism prophylaxis (VTE ppx)	To make sure the patient is appropriately prophylaxed, has a documented reason for withholding VTE ppx, or has therapeutic anticoagulation as appropriate for the comorbid disease states
9	Review home medication list	To ensure nothing has been missed or, if we are holding a home med for a specific reason, when we can resume the home medication again
10	Leave pertinent hand offs for future pharmacists	To be a good wingman/wingwoman and ensure continuity of patient care!

There you have it! My thought process when reviewing a patient chart that I am unfamiliar with.

Chart review for specific consults

Usually, I go into a patient chart because I have a consult. A consult (at my hospital) is when the care team wants Pharmacy to dose or monitor a patient on a specific medication. If this is my reason for going into the chart, I will take a slightly different approach to work up. There are two examples below:

Photo by insung yoon / Unsplash

The steps I take for a vancomycin (vanc) consult

1. Enter the chart

2. Review the recent vanc level and trend of serum creatinine

3. Flip to the pharmacokinetic “navigator” where the initial pharmacist documented the following:

Indication for vanc
Ordering provider
Duration of therapy
Other antibiotics the patient is receiving
Current vanc dosing regimen and predicted AUC:mic
Updated microbiology data

4. Check for any updated microbiology results

I do this to assess for myself if the patient needs to continue vancomycin or if we can de-escalate therapy.

5. Check the most recent provider notes to get an idea of what their plan is or if the Infectious Disease team is consulted

6. Make a clinical decision on whether a level or a change in dose is needed based on renal function

7. Order appropriate changes

8. Leave a handoff for the pharmacist following me the next day

9. Exit the chart!

Photo by ANIRUDH / Unsplash-

The steps I take for a warfarin consult

1. Enter the chart

2. Check the indication for warfarin

3. Review how long the patient has been on warfarin during this admission

a. I do this by looking at my hospital anticoagulation “navigator” where it lays out the last week of previous doses, other anticoagulants/antiplatelets, any interacting medications, pertinent labs, reversal agents, and blood products given

4. Check the INR (obviously)

5. Determine a dose to be given that evening

The table below includes most of what I check prior to ordering a dose of warfarin

Lab/item to Review	Reasoning
History of heart failure	An active heart failure exacerbation may increase response to warfarin in some patients
Liver Function Tests (LFTs)	If the LFTs are elevated, and the liver is not functioning properly, then adequate clotting factors may not be produced. In addition, the vitamin K pathway will be impaired. Response to warfarin may be increased
Diet	If the patient is not eating or has <50% meal consumption, they may have an increased response to warfarin
Weight	Patients with normal or underweight BMI may require less warfarin than a patient with a BMI >40
Age	Older patients (>65) may be more sensitive to the effects of warfarin
Previous warfarin therapy	This gives me a reference to how much warfarin the patient has previously required to be in therapeutic range
Interacting medications	If there are new interacting medications added during admission, the patient may have an altered response to warfarin
INR	If the INR is trending up quickly from the previous doses, I will be more conservative with the next dose. If the INR is not budging, I will be more aggressive. Occasionally, I will order a repeat INR for early afternoon to assess the trend if there is any concern in how sensitive the patient is to warfarin
Hemoglobin and hematocrit (H/H)	If there is an acute drop in the H/H, I will clarify with the provider if they want to administer or hold warfarin for that day
Clinical status	To assess for upcoming procedures or any tubes/drains that will need to be removed. If this is the case, I will clarify dosing with the provider and either hold warfarin or be less aggressive
Indication for warfarin therapy	Totally honest here: I do not trust the stated INR goal in previous notes. Sometimes I find that the goal is incorrect (MVR could be interpreted as “mitral valve replacement” instead of “mechanical valve replacement”) or sometimes the patient does not require warfarin therapy anymore. Therefore, I ensure that I know the true indication for anticoagulation
Recent prothrombin complex concentrate (i.e. KCENTRA) or vitamin K administration	If a large dose of vitamin K was given within the past week, the response to warfarin will be blunted
Adherence to therapy outpatient	If the patient is not adherent outpatient, it is important to discuss with the team the best option for anticoagulation moving forward. Nonadherence to their home regimen lets me know that their outpatient regimen might not be what they need to be in therapeutic range

6. Make a clinical decision on the dose for that evening

7. Order the dose

8. Exit the chart!

Do you routinely check something that I missed? Comment down below!