C3.1 R4(h): Provide continuity of care from in-hospital to outpatient setting #2

Discharge counselling for a 47 yo male admitted with psychosis

  • Counselled on medications, indications, regimens and side effects
    • In hospital, patient was on olanzapine 5mg daily and 10mg HS
      → Counselled that regimen has been changed to 15mg HS
      (Same daily dose, but changed to a once daily dosing for compliance)
    • In hospital, patient was on divalproex EC 250mg daily and 500mg HS
      → Counselled that regimen has been changed to 750mg HS
      (Same daily dose, but changed to a once daily dosing for compliance)
    • In hospital, patient was on phenytoin 200mg twice daily
      → Checked with patient that he has not had any seizures while on phenytoin
      (Patient stated on medication for 15-20 years and when he was compliant to the medication, he did not have any seizures)
      → Checked with patient if there were any difficulties in compliance and discussed importance of medication (had been previously non-compliant to medication)
      → Phenytoin concentration in hospital was sub-therapeutic (see for reference: https://shermainengorx.wordpress.com/2016/09/29/c3-1-r4e-perform-document-a-phenytoin-pharmacokinetic-interpretation/)

      • Next phenytoin blood work was due today, but postponed and to be done in the community
      • Counselled on importance of getting blood work  with AOT to ensure that his steady-state concentration is within therapeutic range
    • In hospital, received paliperidone 100mg IM q 4 weeks.
      • Counselled that next dose is due on Oct 14, 2016 (AOT team goes to his residential area and administers medication)
    • In hospital, patient was on nicotine replacement therapy – 21mg patches and 4mg gums PRNs (Able to decrease smoking from 3 packs per day to 1-2 cigarettes per daily)
      • Counselled about pharmacare’s coverage for NRTs
      • Patient had already used coverage for this year; however, was not successful in quitting
      • Counselled about other measures for smoking cessation
      • Discussed other drug measures for smoking cessation and advised patient to see GP to further discuss appropriate options
  • Discharge prescription was written for daily dispense in community; however, patient fell and hurt his leg. Unit clerk coordinated with AOT team so that medications were temporarily delivered to the AOT team and the AOT would deliver medications daily to patient.
  • Patient did not want any patient information handouts
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