Test 1 Documentation of Pharmacotherapy Interventions Flashcards
1
Q
List reasons why pharmacists document
A
- To record pertinent facts, findings, and observations about a patient’s health history
- To outline ones thought process
- To demonstrate value within an organized healthcare
- It is the accepted method by which healthcare providers communicate with one another
- It reduces the potential for fatal and nonfatal medical errors
- For reimbursement
- For legal hearings
2
Q
Identify barriers to documentation
A
- Time • Knowledge
- Comfort level
- Lack of reimbursement
- Reports generated for workload analysis, accreditation
- Paper documenting = inconsistent reporting
3
Q
List qualities of a well-written patient document
A
- Clear
- Patient focused
- Concise
- Accurate
- Timely
- Ensure patient confidentiality
- Nonjudgmental
- Standardized
- Approved abbreviations*
- Legible
- Includes date of encounter
- Purpose is identified
- Status of control is stated
- Recommendations are clear
- Actions taken are clearly indicated
- Follow-up plan is documented
- Signature and printed name
4
Q
Subjective
A
- purpose of visit
- info from pt
- qualitative info
- not confirmed with test
- opinion
- provides insight into severity of condition
- matches info discussed in A and P
5
Q
Objective
A
- quantitative measurements observed by clinician
- observable
- reproducible
- matches info discussed in A and P
6
Q
Assessment
A
- based on S and O
- what the pharmacist thinks the problem is
- diagnosis
- reason for plan
- how pharm. arrived at the assessment
7
Q
Plan
A
- actions to be taken by patient or provider
- specific changes in treatment / goals
- monitoring
- follow up
