MTM Documentation questions with accurate answers
define SOAP notes Ans✓✓✓ concise report of the pertinent details
from your encounter
how should the assessment section in SOAP be organized? Ans✓✓✓ -
numbered list of disease states
- can include drug therapy problem (DTP) name
- prioritized from most urgent to least urgent
how should the plan section of SOAP be worded? Ans✓✓✓ - be clear
on what you have done vs what you are recommended someone to do
- be clear if the change has been made or if you are recommending it
- use active voice and start with verbs
how to make a correction in documentation Ans✓✓✓ - single line
strikethrough
- note error and initial/date for time of correction
- provide correction
what are assessment phrases Ans✓✓✓ - controlled/noncontrolled
- stable/unstable
- goal/not at goal
- subtherapeutic/supratherapeutic
- improved/unimproved
, - resolved/worsening
what are examples of unstructured communication? Ans✓✓✓ -
narrative notes
- phone encounters where relaying/recording information
what are pertinent negatives Ans✓✓✓ - 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
- pt denies ____
- (-) for ____
what are pertinent positives? Ans✓✓✓ - used to rule in an assessment
- pt reports/admits/acknowledges, notes, endorses ___
- (+) for ____
what are the 4 structured documentation styles? Ans✓✓✓ - SOAP(E)
- SBAR(O)
- FARM (monitoring focused)
- TITRs (assessment focused)
what are the benefits to structured communication? Ans✓✓✓ - quickly
find information
- format helps writer avoid omissions
define SOAP notes Ans✓✓✓ concise report of the pertinent details
from your encounter
how should the assessment section in SOAP be organized? Ans✓✓✓ -
numbered list of disease states
- can include drug therapy problem (DTP) name
- prioritized from most urgent to least urgent
how should the plan section of SOAP be worded? Ans✓✓✓ - be clear
on what you have done vs what you are recommended someone to do
- be clear if the change has been made or if you are recommending it
- use active voice and start with verbs
how to make a correction in documentation Ans✓✓✓ - single line
strikethrough
- note error and initial/date for time of correction
- provide correction
what are assessment phrases Ans✓✓✓ - controlled/noncontrolled
- stable/unstable
- goal/not at goal
- subtherapeutic/supratherapeutic
- improved/unimproved
, - resolved/worsening
what are examples of unstructured communication? Ans✓✓✓ -
narrative notes
- phone encounters where relaying/recording information
what are pertinent negatives Ans✓✓✓ - 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
- pt denies ____
- (-) for ____
what are pertinent positives? Ans✓✓✓ - used to rule in an assessment
- pt reports/admits/acknowledges, notes, endorses ___
- (+) for ____
what are the 4 structured documentation styles? Ans✓✓✓ - SOAP(E)
- SBAR(O)
- FARM (monitoring focused)
- TITRs (assessment focused)
what are the benefits to structured communication? Ans✓✓✓ - quickly
find information
- format helps writer avoid omissions
