Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Patient Care Skills 2 > Documentation of Patient Care > Flashcards

Documentation of Patient Care Flashcards

1
Q

Why do we document patient care activities?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

If you didn’t document it…

A

it didn’t happen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Where do we document patient care activities?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Structured Communication HCPs see

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Unstructured Communication HCPs see

A

narrative notes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is TITRS and what does it stand for?

A

structure documentation type
Title
Introduction
Text
Recommendation
Signature

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is FARM and what does it stand for?

A

structured documentation type
Findings
Assessment
Recommendations/Resolutions
Monitoring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is SOAPE and what does it stand for?

A

type of structured documentation
Subjective
Objective
Assessment
Plan
Education

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is SBARO and what does it stand for?

A

type of structured documentation
Situation
Background
Assessment
Recommendation
Outcomes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

When to do a full soap note?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

When to do an abbreviated soap note

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Subjective (SOAP)

A

descriptive info that cannot be confirmed by diagnostic tests/ procedures

patient/caregiver reported info

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Objective (SOAP Notes)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Assessment (SOAP notes)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Plan (SOAP Notes)

A

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

17
Q

Chief complaint (CC)

A

introduces patient, care setting, and reason for encounter

18
Q

History of Present Illness (HPI)

A

a chronological, accurate recent history relating to chief complaint

19
Q

pertinent positives

A

used to rule-in an assessment
part of HPI

20
Q

pertinent negatives

A

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

21
Q

Past medical history (PMH)

A

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

22
Q

Surgical History

A

think whether relevant or not to encounter
give dates if available

23
Q

Medication list/history

A

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

24
Q

Allergies

A

could be known as NKDA or NKA
may note intolerances separately

25
Q

Immunization history

A

includes type of vaccine and date received

26
Q

Family history

A

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

27
Q

Social History

A

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

28
Q

Review of Systems

A

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

29
Q

What goes in the objective category?

A

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

30
Q

What does SBAR stand for?

A

Situation
Background
Assessment
Recommendation

31
Q

You should avoid words that imply care/products were

A

substandard, incorrect

32
Q

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

A

yes

33
Q

If you make an error should you erase it?

A

no, single line strike through

34
Q

Pharmacist eCARE plan

A

uniform documentation
data can be pulled from systems and sent elsewhere

Patient Care Skills 2 (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions