End-stage renal disease patients represent a complex medical population with multiple comorbid conditions and, therefore, complex medication regimens that may lead to noncompliance, and drug-drug and drug-food interactions. Acutely ill dialysis patients' cases are even more complicated and are prone to iatrogenically induced problems. For these reasons, this patient population should be targeted to receive clinical pharmacy services. This article outlines the evolution of clinical pharmacy nephrology consultative services at a large county teaching hospital over the past decade. Consultative activities for ambulatory and hospitalized patients include therapeutic drug monitoring, medication reviews, dosage modifications, patient counseling, and suggestions for alternative therapeutic selections. Documentation of clinical services is essential to track both written and non-written recommendations and to quantitate clinical activity levels. Documentation procedures are described, and examples of the documentation form and coding list are supplied. Reimbursement procedures for clinical nephrology consultative services which may be applicable in other outpatient clinical settings are discussed.
Practicing pharmacists' patient counseling skills in the context of reflectivity
