UNIT 2- DOCUMENTATION OF PHARMACOTHERAPY INTERVENTIONS.docx...

This preview shows page 1 - 3 out of 9 pages.

UNIT 2: DOCUMENTATION OF PHARMACOTHERAPY INTERVENTIONS If there is no documentation, then it didn’t happen!. This philosophy is the standard in all health care settings as physician, nurses, respiratory therapist, physical therapist, social workers, and other health care providers generate and maintain detailed notes regarding the patient’s situation and their efforts to achieve the best possible outcomes for the patient. Documentation chronologically outlines the care the patient received and serves as a form of communication among health care practitioners. General components of documentation include: A complete and legible record; Documentation for each encounter with a rationale for the encounter, physical findings, prior test test, assessment, clinical impressions (or diagnosis) and plan for care; Identified health risk factors, and an easily inferred rationale for ordering diagnostic test or ancillary services; and The patient’s progress, response to and changes in treatment, and revisions of the original diagnosis/assessment. PRINCIPLES OF DOCUMENTATION Documentation in the record is required to record pertinent facts, findings, and observations about a patient’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. Also facilitates: the ability of providers to evaluate and plan the patient’s immediate treatment and monitor his/her health care over time; Communication and continuity of care among providers involved in the patient’s care; Accurate and timely claims review and payment; Appropriate utilization review and quality of care evaluations; Collection of data that may be useful for research and education; Appropriate coding for use on health insurance claim forms should be supported by documentation in the patient record. most if not all physicians, nurse practitioners, physician associates, and other health care practitioners have been taught to write progress notes using Subjective, Objective, Assessment, Plan (SOAP) format. the example elements of SOAP are as follows: S = Subjective: Chief complaint; history of present illness; why the patient is being seen; O = Objective: Evaluation of the patient, which may include appearance, mood, affect, mental status;
A = Assessment: Analysis or conclusion about the patient’s current status/behavior, evidence of progress, response to intervention or medication, and change in functional status; P = Plan: Interventions or ations taken in response to assessment, collaboration with others, plan for the next session, change in diagnosis, and documentation that the patient was informed of changes in intervention or medications. EVOLUTION OF PHARMACIST-PROVIDED CARE AND THE IMPORTANCE OF DOCUMENTATION Pharmacist-provided care has gone through a long evolutionary process, and continues to bring changes.

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture