Answering Case-Based Exam Questions Flashcards
What is the patient medical record (PMR)?
The patient medical record (PMR) provides complete documentation of a patient’s medical history at a particular institution
*can be referred to as the “medical record” or the “patient chart”
How do EHRs improve accuracy and efficiency?
EHR provides current and previous lab results (by selecting a date range that can go back years in time) which are used to determine if this is a new or an old finding and what recent workup has been completed
What are the advantages of electronic health records?
EHRs allow providers to have immediate access to information when they are off-site. Procedures with results recorded on paper or faxed records from another facility can be quickly scanned into the EHR
What are the advantages of the EHR being linked to Computerized Prescriber Order Entry (CPOE) and electronic prescribing?
- The problem of illegible handwriting is eliminated
- The CPOE system can be designed to present only formulary drugs with proper dosing as options
What are clinical decision support tools?
Clinical decision support (CDS) tools can be built into the order entry process which include order sets, pathways, limited drop down menus that reflect the preferred drug/s, drug interaction and dose checking alerts
What is HIPAA?
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires security protections for all individually identifiable health information, called protected health information (PHI) and these protections apply to both paper records and electronic records
How are EHRs HIPAA protected?
For electronic records, access is limited with PINs and passwords. The information is encrypted and there is an audit trail to track access
*All personnel using the EHR are responsible for security and education on security must be continual
What are the first additions to the patient medical record?
The first addition to the patient medical record are the patient’s demographic data (including insurance information), admission sheet, a service agreement form, a page describing the patient’s rights and an advanced directive
*Allergies may be here or listed in a separate area of the chart
What is an advanced directive?
An advance directive documents the patient’s wishes concerning medical treatment if they are unable to make decisions on their own behalf
Why do religious beliefs need to be documented in the PMR?
Certain religious groups will refuse blood transfusions and blood products, which will need to be documented in the PMR
What are some other forms or sections that can be in a PMR?
Other forms or sections in the PMR include progress notes, the vital signs record, laboratory tests, monitoring records used for some medications, medication administration records and procedures records, including the diagnostic and operating room records
What should you avoid when documenting information in the PMR?
When documenting information in the PMR, it is important to avoid abbreviations that could be interpreted to mean something else
Why do interventions require documentation?
Interventions require documentation for reimbursement since the quality of care is (increasingly) tied to the payment
*Departments of pharmacy should have policies in place that describe the authority of pharmacists to document in the PMR, what activities will be documented and the proper format for documentation
What are examples of activities that pharmacists document in the PMR?
Patient counseling, medication histories, consultations and dosage adjustments
How do the Centers for Medicare and Medicaid Services play a role in reimbursement?
CMS has penalties for poor care and incentives for quality care
What are two areas in which the CMS gives steep penalties?
Two areas in which the penalties are steep are the rate of hospital-acquired infections and the hospital’s readmission rate. These measures are chosen because they are expensive and are often, but not always, avoidable.
What are the Joint commission, the Pharmacy Quality Alliance (PQA) and the Agency for Healthcare Research and Quality (AHRQ) involved in?
Setting the criteria to measure the quality of care
What are some specific goals for PQA quality measurements?
Specific goals include increasing adherence, avoiding unnecessary or unsafe medications and increasing the use of medications indicated for certain conditions
What is Medicare and describe the different parts of Medicare?
Medicare is the federal health insurance program for people > 65 years old, < 65 with disability and all ages with end stage renal disease (ESRD). The prescription drug benefit under Medicare is called Part D. Part A covers the hospital visit and Part B covers medical costs, such as doctor visits and some vaccines
What is Medicaid?
Medicaid provides health insurance for all ages with very low income (< 133% of the federal poverty level). Medicaid is a federal and state program and a senior who qualifies for both Medicare and Medicaid has “dual coverage”
What is the SOAP format?
One common method of organizing a progress note consisting of four parts: Subjective, Objective, Assessment and Plan
What is the 1st section in a SOAP note?
the 1st section in a SOAP note is the subjective information recorded from the patient. It is the patient’s narrative fo their symptoms.
*The person conducting the interview should used open-ended and direct questions while avoiding closed-ended and leading questions
What does the subjective section contain?
- A one line chief complain (CC) which is the specific reason the patient is being seen today
- A detailed history of present illness (HPI) which contains the onset and duration of the complaint, the quality and severity, any modifying factors that reduce or aggravate the condition, treatments that have been tried and the effect of the treatment
- A detailed past medical history (PMH) with social history, family history, allergies and patient-reported medication use (medications include prescriptions, OTC drugs, vitamins and natural products)
What is the second section in a SOAP note?
The 2nd section in a SOAP note is the objective information obtained by the clinician, either through observation or analysis
What does the objective section include?
- Vital signs (respiration rate, heart rate, blood pressure and temperature)
- Other measurements (e.g. height and weight), physical findings, diagnostic tests performed and laboratory results go into this section
- The medication list if it is obtained from a source other than the patient because it was objectively verified
What are critical results?
Critical results are lab values significantly outside the reference range and must be reported to a healthcare provider and addressed quickly as they can indicate a life-threatening situation
How do you convert from celsius to farenheit and vice versa?
C = (F - 32)/1.8
F = (C x 1.8) + 32
What are some examples of conditions that can increase blood pressure?
Renal insufficiency/failure, pregnancy, excess salt intake, obesity, adrenal tumors
What are some drugs that can cause hypotension?
Antihypertensives, vasodilators, opioids, benzodiazepines, anesthetics, phosphodiesterase inhibitors
What are some conditions that can cause hypotension?
Anaphylaxis, blood loss, infection (esp. sepsis), dehydration (orthostatic hypotension)
What are some medications that can cause tachycardia?
Stimulants (ADHD, weight loss drugs), decongestants, beta agonists (esp. overuse), theophylline (esp. in toxicity), anticholinergics (tricyclics, antihistamines), bupropion, antipsychotics, excess caffeine/nicotine, illicit drug use, vasodilators (e.g. nitrates, hydralazine, DHP CCBs)
What are some conditions that can cause tachycardia?
Some arrhythmias (atrial fibrillation, ventricular tachycardia), hyperthyroidism, anemia, dehydration, anxiety, stress, pain, hypoglycemia, infection, drug withdrawal, serotonin syndrome
What are some medications that can cause bradycardia?
Beta-blockers, non-DHP CCBs, digoxin, clonidine, guanfacine, antiarrhythmics (esp. Class III), opioids, sedatives, anesthetics, neuromuscular blockers, acetylcholinesterase inhibitors
What are some conditions that can cause bradycardia?
Some arrhythmias (sinus bradycardia), hypothyroidism
What is a medication that causes tachypnea?
Stimulants
What are some conditions that can cause tachypnea?
Asthma and COPD (esp. when poorly controlled), anxiety, stress, ketoacidosis, pneumonia
What are some medications that can cause respiratory depression?
Opioids, sedatives
What are some conditions that can cause respiratory depression?
Hypothyroidism
What are some medications that can cause hyperthermia?
Inhaled anesthetics (malignant hyperthermia), antipsychotics (neuroleptic malignant syndrome), topiramate
What are some conditions that can cause hyperthermia?
Fever, hyperthyroidism (esp. thyroid storm), trauma, cancer, serotonin syndrome
What are some conditions that can cause hypothermia?
Exposure to the cold, hypothyroidism (esp. myxedema coma), hypoglycemia
What is the 3rd section of a SOAP note?
The 3rd section is the assessment and this is the provider’s thought process of possible causes of the current situation
What does the assessment include?
The assessment will often include a differential diagnosis, which is a list of possible diagnoses that could explain the patient’s current signs and symptoms
What is the 4th section of SOAP note?
The 4th section is the plan and this is how the problem/s will be addressed and should be as specific as possible
What is included in a plan and what is done to develop a plan?
- Labs might be ordered, the patient might require diagnostic exams, referrals may be requested or the patient may require education
- If there is a differential diagnosis, there will be multiple steps in the plan to eliminate some of the possible conditions
How is time recorded in all medical records?
In all medical records, including the SOAP note, time is recorded with a 24 hour clock, rather than splitting the day into two 12-hour segments
What is the 24 hour clock called and how do you use it?
The 24 hour clock is called military time. The day begins at midnight which us called 24:00 or 0:00. After 12:00 noon, the time continues on the same number scale for the rest of the day (e.g. 2 pm = 14:00). The last minute of the day is 23:59, then 24:00 and then the next day begins
How do you convert military time back to 12 hour segments?
To convert military time back to 12 hour segments, simply subtract 12 from any number > 13
How do you look for medication problems in a patient case?
Review the case for the following medication problems: untreated medical conditions, medications used without an indication, improper drug selection, dose that is too low or high, therapeutic duplication, lack of patient understanding about medication, drug allergy, drug interaction, improper use of medication, failure to receive medication, adverse drug reaction, nonadherence
What is the method used for recommending drug therapy questions?
Read the question and answer choices first, before extensively evaluating the case. After you read the question, you should be able to quickly determine what information you need from the case
What is health literacy?
Health literacy is the degree to which individuals are able to obtain, process and understand basic health and medication information to make appropriate health decisions
*different that simply being able to read or being well educated
What are some effective communication and education strategies?
- Approach all patients as if they may not understand the health information presented
- Use non-medical language that patients can understand
- Ask open ended questions
- Avoid leading questions
- Confirm understanding
- Use different communication (verbal, written, visual aids)
- Use active listening
- Speak clearly, make eye contact, introduce yourself and refer to patients by their name
