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53 Cards in this Set

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