iRat SOAP Notes Proctored Exam Complete Actual Questions With Correct Answers/2024.

Describe the purposes for documenting patient care. - correct answer 1. SOAP notes protect the rights of the pharmacist and the patient in the event there is a question regarding the care of the patient. 2. SOAP notes are means of communication between pharmacists and other health care professionals and provide consistency among the services provided by various health care professionals 3. Third party payers make decisions on reimbursements based on quality and completeness of the documentation of patient care 4. The SOAP note method is an excellent method of structuring critical thinking for clinical decision making 5. Documentation of patient care can be used for continuous quality improvement 6. Documentation of patient care is used in outcomes research. 7. Documentation can serve as a reminder for yourself, what you did and what you plan to do Identify the components of a SOAP note - correct answer Subjective, Objective, Assessment and Plan Identify where the information for the SOAP note components comes from. - correct answer SOAP notes comes from the patient interview, tests like the vital signs (blood pressure, pulse, temperature, resiration rate), height, weight, and laboratory values and the pharmacist assessment When given patient information, determine the category for a SOAP note (i.e. subjective, objective, assessment, or plan) and where it should be documented - correct answer Patient information is subjective information in SOAP notes and it should be documented in the subjective information section Differentiate Subjective and Objective information. - correct answer Subjective information is information obtained from interviewing the patient. An item belongs in this section if the patient tells the pharmacist information. Objective information is information obtained from the chart with info such as vital signs, height, weight and laboratory tests. Recognize how subjective and objective sections of the SOAP note provide the support for the development of the Assessment and Plan sections. - correct answer .. Identify the key elements of the Assessment and Plan. - correct answer Assessment should have current status of the disease, diagnosis or problems of a patient (in order of most significant to lease significant) Plan is based on subjective, objective information and the assessment. For every problem listed in the Assessment section, there should be an item in the Plan section. The plan items should be in the same order as the problems listed in the Assessment section. Describe the guidelines for documenting patient care. - correct answer 1. Accuracy 2. Brevity 3. Clarity 4. Punctuation 5. Correcting Errors 6. Signing Your Notes Apply guidelines for documenting patient care to identify errors in SOAP notes and provide recommendations for improving the documentation of patient care. - correct answer ...