Documentation Flashcards
A review of the medical conditions and symptoms to determine the need for drug therapy
Assesment
A decision of an appropriate drug therapy based on the assessment of the patient
Plan
A review of the
of an
outcomes of
integrated
drug therapy to
monitoring
determine if the
plan
patient is obtaining the desired outcomes
Monitoring
A patient-centered practice in which the practitioner assumes responsibility for a patient’s drug- related needs
Pharmaceutical care
Responsible provision of drug therapy for the purpose of achieving definite outcome
Pharmaceutical care
A complete and legible record
Collection of data that may be useful
To evaluate and plan the patient’s immediate treatment
Documentation
required to record pertinent facts, findings, and observations about a patient’s health history
Documentation
A distinct service or group of services that optimize therapeutic
outcomes individual patients.
Patient centered assessment
Medication therapy management
A systematic process of collecting patient-specific of aninformation, assessing medication therapies to identify medication-related problems,
Medication therapy review
A comprehensive record Development
of the patient’s medications (prescription
and non-prescription medications,
Personal medication record
a patient- centric document containing a list of actions for the patient to use in tracking progress for self-management.
Medication-related action plan
Basic information: address, phone, e-mail, gender, age, ethnicity, education status, patient’s special needs, health plan benefit/insurance
coverage
Patient demographic
A record of all medications, including prescription and nonprescription medications,
PMR
Patient-centric document containing a list of actions to use in tracking progress
for self-management
MAP
Transition plan or scheduling of next follow-up visit
Follow-up
