Therapeutics- Clinical Documentation of Patient Care

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Terms in this set (...)

Define the need for patient care documentation.
-Provides a standard of practice
-Demonstrates evidence of pharmacists contribution to high quality, evidence driven carer
-Establishes a criteria for third party payer reimbursement
-Reflects a patient agreement with their health care provider
What documentation style is used for monitoring?
FARM
What does FARM stand for?
Findings
Assessment
Recommendation
Management
What documentation style is used for assessment?
TITRS
What does TITRS stand for?
Title
Introduction
Text
Recommendation
Signature
What documentation style is used for intervention?
SOAP
What does SOAP stand for?
Subjective
Objective
Assessment
Plan
Chief complaint (CC) would be found in what part of a SOAP note?
Subjective
History of present illness (HPI) would be found in what part of a SOAP note?
Subjective
Past medical history (PMH) would be found in what part of a SOAP note?
Subjective
Past surgical history would be found in what part of a SOAP note?
Subjective
Family history (FH) would be found in what part of a SOAP note?
Subjective
Home medications (Rx, OTC) would be found in what part of a SOAP note?
Subjective
Allergies would be found in what part of a SOAP note?
Subjective
Social History (SH) would be found in what part of a SOAP note?
Subjective
Review of systems (ROS) would be found in what part of a SOAP note?
Subjective
Vitals would be found in what part of a SOAP note?
Objective
Measurements would be found in what part of a SOAP note?
Objective
Physical exam would be found in what part of a SOAP note?
Objective
Laboratory results would be found in what part of a SOAP note?
Objective
Diagnostics/Imaging would be found in what part of a SOAP note?
Objective
Cultures would be found in what part of a SOAP note?
Objective
Procedures would be found in what part of a SOAP note?
Objective
Current medications would be found in what part of a SOAP note?
Objective
What are 3 questions to be asked about problems when assessing a patient?
1. What is the evidence that this is a problem?
2. What are the goals of therapy?
3. What is the drug therapy problem?
What are 7 drug therapy problems?
1. Unnecessary drug
2. Needs additional drug
3. Wrong or ineffective drug
4. Dose too high
5. Dose too low
6. Adverse Drug Reaction
7. Adherence
What are benefits of documentation?
1. Reimbursement
2. Value of pharmacist driven services
What are challenges of documentation?
1. Reimbursement
2. Time