Documentation & Clinical Communication Flashcards
7 cards from real MTM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation & Clinical Communication flashcards as text
Which component of a SOAP note contains the pharmacist's assessment of a drug-related problem identified during an MTM encounter?
Answer: Assessment
The Assessment section of a SOAP note is where the clinician documents their professional interpretation of findings, including identified drug-related problems.
When documenting a Comprehensive Medication Review (CMR), the Personal Medication Record (PMR) must include which of the following for each medication?
Answer: Medication name, dose, frequency, and indication
CMS requires the PMR to include medication name, strength, dose, frequency, route of administration, and indication for each medication.
A pharmacist is documenting a Medication Action Plan (MAP) after a CMR. The MAP is best described as a patient-centered document that:
Answer: Outlines action steps the patient and care team will take to address medication issues
The MAP is written in patient-friendly language and lists specific action steps for the patient and/or care team to address identified medication-related problems.
Under HIPAA regulations, a pharmacist conducting an MTM session by phone must:
Answer: Verify the patient's identity before disclosing protected health information
HIPAA requires verification of patient identity before disclosing PHI in telephone encounters to prevent unauthorized disclosure.
Which CMS billing code is used to document a Targeted Medication Review (TMR) with follow-up intervention for Medicare Part D MTM programs?
Answer: 99606
CPT code 99606 is used for MTM services provided by a pharmacist for an established patient, including a TMR with intervention, lasting up to 30 minutes.
When a pharmacist sends a written recommendation to a prescriber following an MTM encounter, the communication should include:
Answer: The specific drug-related problem, proposed intervention, and clinical rationale
Effective interprofessional communication to prescribers must clearly identify the drug-related problem, the recommended intervention, and the evidence-based rationale.
Documentation of a patient's adherence barriers during an MTM visit is MOST appropriately recorded under which section of a structured MTM note?
Answer: Subjective information
Adherence barriers reported by the patient constitute subjective information, as they reflect the patient's self-reported experiences and perceptions.