FIPP 5 EXAM #1 STUDY GUIDE
PURPOSES OF DOCUMENTATION - 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: - Answer -subjective, objective, assessment, plan
Subjective - Answer -• Information provided by the patient, family, or caregiver •
Thorough, but concise• Descriptive and can not be measured directly
Chief COmplaint - Answer -• Patient's complaint in their own words•
Usuallyprovidedinquotes• Thepatientmaynotalwaysprovideaspecific
complaint
History of Present Illness (HPI) - Answer -information gathered regarding the symptoms
and nature of the patient's current concern
Past medical history (PMH) - 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) - 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) - Answer -An age-appropriate review of past and current activities
(smoking, alcohol, etc.)
Medications (SOAP Notes) - 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) - Answer -What is the allergy and reaction?
When did this occur?
, • If none, write NKDA
○ No Known Drug Allergies
NKDA - Answer -No known drug allergies
Review of systems (ROS) - 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 - 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 - Answer -•
Should include:
○ BP
○ HR
○ RR
○ Temperature
○ Height
○ Weight (kg)
○ Body mass index
Physical Exam - Answer -• Includes pertinent observations & results of any physical
exams, broken down by organ system
Laboratory Tests - Answer -Includes pertinent lab values for the patient such as:
○ Basic Metabolic Panel (BMP)
○ Complete Blood Count (CBC)
May also include any additional pertinent labs such as:
○ Lipid panel
○ Blood glucose
○ Hemoglobin A1C
○ Pregnancy test
Serum Drug Concentrations - Answer -• Include results for drugs that require blood
drug monitoring such as:
• Vancomycin • Phenytoin• Valproic acid
Diagnostic Tests - Answer -broad spectrum diagnostic tests such as: EKG, X-rays,
blood culture
Problem List - Answer -⮚Prioritized by importance ⮚Problems are numbered
PURPOSES OF DOCUMENTATION - 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: - Answer -subjective, objective, assessment, plan
Subjective - Answer -• Information provided by the patient, family, or caregiver •
Thorough, but concise• Descriptive and can not be measured directly
Chief COmplaint - Answer -• Patient's complaint in their own words•
Usuallyprovidedinquotes• Thepatientmaynotalwaysprovideaspecific
complaint
History of Present Illness (HPI) - Answer -information gathered regarding the symptoms
and nature of the patient's current concern
Past medical history (PMH) - 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) - 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) - Answer -An age-appropriate review of past and current activities
(smoking, alcohol, etc.)
Medications (SOAP Notes) - 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) - Answer -What is the allergy and reaction?
When did this occur?
, • If none, write NKDA
○ No Known Drug Allergies
NKDA - Answer -No known drug allergies
Review of systems (ROS) - 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 - 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 - Answer -•
Should include:
○ BP
○ HR
○ RR
○ Temperature
○ Height
○ Weight (kg)
○ Body mass index
Physical Exam - Answer -• Includes pertinent observations & results of any physical
exams, broken down by organ system
Laboratory Tests - Answer -Includes pertinent lab values for the patient such as:
○ Basic Metabolic Panel (BMP)
○ Complete Blood Count (CBC)
May also include any additional pertinent labs such as:
○ Lipid panel
○ Blood glucose
○ Hemoglobin A1C
○ Pregnancy test
Serum Drug Concentrations - Answer -• Include results for drugs that require blood
drug monitoring such as:
• Vancomycin • Phenytoin• Valproic acid
Diagnostic Tests - Answer -broad spectrum diagnostic tests such as: EKG, X-rays,
blood culture
Problem List - Answer -⮚Prioritized by importance ⮚Problems are numbered
