PURPOSES OF DOCUMENTATION Correct Answer-• Improving patient care & outcomes.• Providing patients with information about their care.• Enhancing continuity of care.• Ensuring compliance with laws & regulations.• Protecting against professional liability.• Creating a record of services pr...
FIPP 5 Exam #1 Questions with Correct Answers
PURPOSES OF DOCUMENTATION Correct Answer-• Improving
patient care & outcomes.• Providing patients with information about
their care.• Enhancing continuity of care.• Ensuring compliance with
laws & regulations.• Protecting against professional liability.• Creating a
record of services provided for billing & reimbursement purposes. •
Establishing the pharmacist's credibility as a health care provider.
SOAP Note stands for: Correct Answer-subjective, objective,
assessment, plan
Subjective Correct Answer-• Information provided by the patient,
family, or caregiver • Thorough, but concise• Descriptive and can not be
measured directly
Chief COmplaint Correct Answer-• Patient's complaint in their own
words• Usuallyprovidedinquotes•
Thepatientmaynotalwaysprovideaspecific
complaint
History of Present Illness (HPI) Correct Answer-information gathered
regarding the symptoms and nature of the patient's current concern
Past medical history (PMH) Correct Answer-• Complete listing of
childhood and adult illnesses • Includes diagnosis• Ideally include
duration (or year of diagnosis)• May also include surgical history
,Family History (FH) Correct Answer-● Include FH of first degree-
relatives only
● Mother, father, siblings, and children should all be
listed
● If FH does not impact therapy decision, can write as
non-contributory
● If it is unknown, can document as unknown
Social History (SH) Correct Answer-An age-appropriate review of past
and current activities (smoking, alcohol, etc.)
Medications (SOAP Notes) Correct Answer-• List ALL prescription,
OTC, Herbals, & Supplements
• Include:
○ Drug name (brand & generic)
○ Drug strength
○ Drug route
○ Drug frequency
○ Drug duration of therapy (if appropriate)
Allergies (SOAP Notes) Correct Answer-What is the allergy and
reaction?
When did this occur?
• If none, write NKDA
, ○ No Known Drug Allergies
NKDA Correct Answer-No known drug allergies
Review of systems (ROS) Correct Answer-Set of questions asked that
pertain to symptoms associated with each body system
Will indicate the body system, symptom asked, and which are positive
vs. those that patient denies
If not performed, can document as "deferred"or "not performed"
Objective Correct Answer-• Data obtained by the clinician, EMR, lab
work, and diagnostic tests • Can be measured• Should only include the
pertinent positive and negative findings
Vital Signs Correct Answer-•
Should include:
○ BP
○ HR
○ RR
○ Temperature
○ Height
○ Weight (kg)
○ Body mass index
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