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53 Cards in this Set
- Front
- Back
- 3rd side (hint)
What is the importance of documentation?
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1. Identify potential and actual drug-related problems
2. Resolve actual drug-related problems 3. Prevent potential drug related problems |
Pertains to drug-related problems
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What are the two types of notes used for documentation?
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Through SOAP or FARM notes
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What are the possible formats of progress notes?
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Outline or narrative
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Definition: Standardized outline approach that is in common use to document a patient's course.
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SOAP notes
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List the four sections of the SOAP note.
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1. Subjective data
2. Objective data 3. Assessment 4. Plan |
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Which section of the SOAP notes contains complaints from the patient?
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Subjective
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Which section of the SOAP notes contains "symptoms"?
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Subjective
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Which section of the SOAP notes contains things that can be observed about the patient?
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Subjective
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Which TWO sections of the SOAP notes includes pertinent positive and pertinent negatives from the patient?
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Subjective and Objective
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Which section of the SOAP notes is open to individual interpretation?
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Subjective
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Which section of the SOAP notes generally cannot be confirmed by diagnostic tests or procedures?
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Subjective
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Which section of the SOAP notes is obtained by speaking with the patient about their medical history?
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Subjective
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Which section of the SOAP notes contains what the physician observes by performing a physical exam?
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Objective
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Which section of the SOAP notes contains "signs"?
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Objective
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Which section of the SOAP notes contains the results of laboratory and diagnostic tests?
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Objective
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Which section of the SOAP notes is easily duplicated or quantified?
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Objective
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Which section of the SOAP notes is also known as the "impression"?
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Assessment
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Which section of the SOAP notes contains the problem and its cause or status?
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Assessment
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Which section of the SOAP notes contains "rule outs"?
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Assessment
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Which section of the SOAP notes often takes the form of a diagnosis?
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Assessment
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After reading this part of the SOAP note, one should be able to understand how the clinician arrived at his/her assessment of the problem.
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Assessment
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Which section of the SOAP notes contains the "physician orders"?
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Plan
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Which section of the SOAP notes often uses action verbs?
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Plan
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Which section of the SOAP notes contains all drug and non-drug treatment/management of the patient?
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Plan
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Which section of the SOAP notes contains laboratory and diagnostic tests?
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Plan
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actual test papers?
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Which section of the SOAP notes contains patient education undertaken?
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Plan
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Which section of the SOAP notes contains rationale for changes in pharmacotherapy (including drug/dose/dosage form,etc.)?
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Plan
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Which section of the SOAP notes contains efficacy and toxicity parameters that can be used to see if desired therapeutic outcomes are being achieved?
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Plan
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The ____ note is a pharmacist equivalent of a physician's progress note?
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The FARM note
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What are the sections of the FARM note?
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Findings
Assessment Recommendation/Resolution Monitoring |
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Which section of the FARM note contains the nature of the drug therapy problem (potential or actual)?
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Findings
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Which section of the FARM note contains demographic data?
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Findings
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Which section of the FARM note contains information that supports your findings?
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Findings
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Which section of the FARM note addresses each problem separately?
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Findings
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Which section of the FARM note contains the pharmacist's evaluation of the situation?
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Assessment
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Which section of the FARM note contains the thought process that led to the conclusion that a problem did exist?
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Assessment
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Which section of the FARM note contains the severity and urgency of the problem?
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Assessment
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Which section of the FARM note contains the desired therapeutic endpoint/outcome?
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Assessment
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Which section of the FARM note contains both short term and long term goals?
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Assessment
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Which section of the FARM note contains actions proposed?
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Recommendation/Resolution
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Which section of the FARM note may include pharmacologic and non-pharmacologic therapy?
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Recommendation/Resolution
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Which section of the FARM note contains recommended drug therapy?
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Recommendation/Resolution
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Which section of the FARM note contains rationale for recommended therapy?
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Recommendation/Resolution
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Which section of the FARM note contains information to be conveyed to patient?
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Recommendation/Resolution
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Which section of the FARM note contains documentation even if no action was taken or recommended?
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Recommendation/Resolution
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Who uses SOAP notes?
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Physicians
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Who uses FARM notes?
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Pharmacists
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Which section of the FARM note contains pharmaceutical care?
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Monitoring
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Which section of the FARM note contains follow-up?
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Monitoring
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Which section of the FARM note determines the effect of plan suggested?
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Monitoring
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Which section of the FARM note emphasizes frequency, duration and target endpoint?
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Monitoring
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Which section of the FARM note contains parameteres used to detect or prevent adverse reactions?
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Monitoring
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How are parameters determined?
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By the most common and most serious events known to be associated with an intervention
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