SOAP Flashcards
Patient Presentation (H&P)
- CC
- HPI
- PMH
- FH
- SH
- Allergies
- Medications
- ROS
- PE
- Laboratory data and diagnostic testing
Problem List
Index of all problems
- Active and inactive
- Acute and chronic
Problem identification
- Identify abnormal findings
- Interpret findings
- Identify drug-related problems
Problems may be: symptoms, signs, past health events, diagnosis, adverse drug reactions, and others
Problem List 2
Once you have identified patient problems, you will need to organize into a list
Most active and serious problem should be listed first
- Record date of onset
- Record “inactive” date
Allows other members of the health care team to review the patient’s health status
Challenges of Clinical Data
Clustering data into single vs. multiple problems
Consider
- Age
- Timing of symptoms
- Different body systems
Sifting through extensive array of data
- Analyze one cluster of symptoms at a time
- Use questions to help focus thinking
Challenges of Clinical Data 2
Assessing the quality of the data
Subject to error
Patient related errors
- Omission of symptoms
- Confuse illness
- Avoid reporting embarrassing facts
- Slant stories to what clinician wants to hear
Documenting Information
Value of Documentation
- Provides permanent record
- Provides evidence of patient care activities by the pharmacist
- Communicates essential information to other pharmacists and healthcare professionals
- Serves as a legal record of patient care that was provided
- Provides evidence of patient intervention and medication therapy management services for reimbursement
Documenting Information 2
Various methods
SOAP – widely used
- Physician –focus
PHARME
Pharmacist-focus
ASHP
Pharmacist-focus, designed for Clinical Skills Competition
SOAP Note
Format for documenting patient information
S: Subjective
O: Objective
A: Assessment
P: Plan
Each section reflects a specific type of information
Subjective Data
Information given by the patient, family member, significant others, or caregivers
Makes up the patient history
- Chief complaint
- History of Present Illness
- Past Medical History
- Medication History
- Allergies
- Social/Family History
- Review of Systems
Objective Data
Patient data that can be measured objectively
- Vital signs
- Laboratory test results
- Serum drug concentrations
- Various diagnostic test results
- Physical examination findings
Analysis and Interpretation
Assessment
Involves critical thinking and analysis
Analyze the subjective and objective data to determine:
- Health status of a patient
- Drug related problems
- Include assessment of the drug therapy
- Critique drug therapy - Health outcomes (are they being met?)
Provides the basis or rationale for the plan
Plan
Involves actions that need to be taken to resolve EACH problem that has been identified
Include detail, but do not be too lengthy
Include
- Goals of therapy
- Treatment plan
- Incorporate guidelines
- Pharmacologic and non-pharmacologic
- Referrals to other health care professionals
- Monitoring parameters
- Efficacy and safety
- Plan for follow-up
- Patient education
