SOAP notes Flashcards
SOAP stands for
Subjective
Objective
Assessment
Plan
What are the best sources for clinical information?
The ________________
Medical record
_________ members or others who assist with the patient’s care
The patient’s physician, nurse,social work, and therapists (e.g.) physical therapist
Pharmacists who care for the patient
patient
Family
Putting it all together:
The Clinical Interview
The clinical interview integrates what you have learned regarding interviewing and counseling with the questions pertinent to the patient’s illnesses and drug-related problems
YOU put it all together to evaluate and monitor drug therapy
The patient as a source of information
Able to provide up-to-date subjective information about illness,treatments, history
Able to provide personalized input on treatment plan and its feasibility
Allows for establishing trust and rapport
Patient History
_____________format helps ensure information is complete
Information outlined in a clear,concise, and predictable manner
Facilities communication among other healthcare professionals
Same format used for “Patient Presentation” (Use the pocket guide)
Standardized
Outline for History: What to Ask
Identifying information
Chief _________(CC)
-History of Present Illness(HPI)
-Past medical history (PMH)
-_____History (DH)
-_________ history (FH)
-Social History (SH)
-Review of Systems (ROS)
Complaint
Drug
Family
SCHOLAR-MAC
__________: What are main and associated
sxs?
Characteristics: What are the symptoms like?
_________: Done so far? Happened before?
_________: When did particular problem start?
_________: Where is the problem?
Aggravating factors: What makes it worse?
Remitting factors: What makes it better
Symptoms
History
Onset
Location
SCHOLAR-MAC
Medications: rx and non-rx, natural, herbals,
generic
___________: medication and other with reaction
Conditions: other medical conditions
Allergies
Why are we writing SOAP notes?
Patients have drug-related problems
Physicians have ___________
Document, Document, document!
Write a note with __________! Be an agent of change! Your role is to consult as a pharmacist to care for patients and promote your profession.
questions
purpose
What’s in a Note?
Consider your setting and audience
Setting: retail vs hospital vs clinic
Audience: usually depends on setting
Types of Notes
-Consultation/summary of progress
-D/C (discontine/discharge?)
-Counseling
SOAP
Pharmacist’s assessment
SOAP Note Format
Subjective
Objective
______________ and __________should be listed in subjective or objective depending on the source of information
medications and allergies
SOAP Note Format
_____________:Identification of role of drug therapy in chief complaint and other drug- related problems
As a pharmacist, consider
-Drug-related issues
-Need for additional information
-Patient’s needs
Prioritize drug related issues/ problems
Assessment
SOAP Note Format
___________:Specific action items which build on assessment info
Points should follow the prioritization set in the assessment
Exact dosing (ranges are NOT ok) and duration of therapy
When to assess efficacy-days,weeks,months,years??
Monitoring: adverse events,labs
Needed consultations or referrals (ex:nutritionist, psych, PT/OT, social work,etc)
Medication counseling
Do not repeat information from assessment. Instead, your plan should spell out the specific details (drug, dose,duration) that you allude to in the assessment
Plan
_____________– anything the patient tells you + ROS
Subjective
The ORDER of Subjective
