Documentation of Patient Care

Question 1

Why do we document patient care activities?

Answer 1

allows longitudinal care
communication between patient and other HCPs
legal record of recommendations/actions & rationale
substantiating/determining billed services/level of care
quality, outcomes tracking

Question 2

If you didn’t document it…

Answer 2

it didn’t happen

Question 3

Where do we document patient care activities?

Answer 3

patient medical record
EMR
MTM platforms
Type & Faxed to provider in another organization
Annotated on Rx

Question 4

Structured Communication HCPs see

Answer 4

benefits
quickly find information
format helps writer avoid omissions
templates, efficiency, compliance, reporting for Quality improvement/research

Question 5

Unstructured Communication HCPs see

Answer 5

narrative notes

Question 6

What is TITRS and what does it stand for?

Answer 6

structure documentation type
Title
Introduction
Text
Recommendation
Signature

Question 7

What is FARM and what does it stand for?

Answer 7

structured documentation type
Findings
Assessment
Recommendations/Resolutions
Monitoring

Question 8

What is SOAPE and what does it stand for?

Answer 8

type of structured documentation
Subjective
Objective
Assessment
Plan
Education

Question 9

What is SBARO and what does it stand for?

Answer 9

type of structured documentation
Situation
Background
Assessment
Recommendation
Outcomes

Question 10

What are soap notes and what is the goal of them?

Answer 10

concise report of the pertinent details from your encounter

goal: justify and document your assessment of and plan to manage/monitor each of the patients conditions

Question 11

When to do a full soap note?

Answer 11

documenting initial encounters
cases where note is the only record of information gathered
comprehensive medication reviews

Question 12

When to do an abbreviated soap note

Answer 12

documenting focused/follow-up encounters
communicating recommendations to others
modifier significant/pertinent before note components

Question 13

Subjective (SOAP)

Answer 13

descriptive info that cannot be confirmed by diagnostic tests/ procedures

patient/caregiver reported info

Question 14

Objective (SOAP Notes)

Answer 14

data that can be measured objectively
practitioner observations, labels, info from clinical databases

Question 15

Assessment (SOAP notes)

Answer 15

summarizes the pharmacists evaluation of the collected subjective and objective info
sets up the problems to be addressed by the plan

organized by disease state in a numbered list, most to least urgent

incorporate evidence-based goals of care

asses possible causes of drug therapy problems, diseases states, and medications

Question 16

Plan (SOAP Notes)

Answer 16

parallels, assessment, and states how each problem will be addressed
new, changed, discontinued, or maintained therapies
education
monitoring/follow up/referrals
use collaborative language and consider scope of practice
use active voice and start with verbs

Question 17

Chief complaint (CC)

Answer 17

introduces patient, care setting, and reason for encounter

Question 18

History of Present Illness (HPI)

Answer 18

a chronological, accurate recent history relating to chief complaint

Question 19

pertinent positives

Answer 19

used to rule-in an assessment
part of HPI

Question 20

pertinent negatives

Answer 20

used to rule-out other possible assessments or to establish that patient is not experiencing a particular adverse event or does not have a contraindication to therapy

part of HPI

Question 21

Past medical history (PMH)

Answer 21

distinguish current vs resolved health conditions
may also be current medical history

Question 22

Surgical History

Answer 22

think whether relevant or not to encounter
give dates if available

Question 23

Medication list/history

Answer 23

name, strength, dosage form, route, frequency, duration
include OTCs and dietary supplements
may use a table

Question 24

Allergies

Answer 24

could be known as NKDA or NKA
may note intolerances separately

Question 25

Immunization history

Answer 25

includes type of vaccine and date received

Question 26

Family history

Answer 26

first-degree relatives, who has which conditions, age or cause of death

Question 27

Social History

Answer 27

tobacco/nicotine EtOH Illicit/recreational drug use diet/physical activity sexual history psychosocial factors/ social determinants

Question 28

Review of Systems

Answer 28

head to toe review checking for symptoms comprehensive medication reviews may be targeted to areas of concern in disease/mgmt visits

Question 29

What goes in the objective category?

Answer 29

vital signs - with date, time, AND units height & weight labs clinical calculations physical exams diagnostic tests meds/immunizations

Question 30

What does SBAR stand for?

Answer 30

Situation Background Assessment Recommendation

Question 31

You should avoid words that imply care/products were

Answer 31

substandard, incorrect

Question 32

Do patients have access to their EMR portal or medical records?

Answer 32

yes

Question 33

If you make an error should you erase it?

Answer 33

no, single line strike through

Question 34

Pharmacist eCARE plan

Answer 34

uniform documentation data can be pulled from systems and sent elsewhere