SOAP notes

Question 1

4 components of a SOAP note

Answer 1

subjective
objective
assessment
plan

Question 2

2 types of patient assessment

Answer 2

System based assessment

Problem based assessment

Question 3

System based assessment

Answer 3

organize by organ system (cardio, neurological, GI)

Used for complex critically-ill patients

Question 4

Problem based assessment

Answer 4

Used when a disease requires multiple facets of management

ex: diabetes, MI

Question 5

Subjective

Answer 5

CC
HPI
PMH
Past surgical history
FH/SH
Allergies
Med list/immunizations/home monitoring

Question 6

Objective

Answer 6

Vital signs
Physical exam
Pertinent labs
diagnostic test
Calculations: Cockcroft-Gault, weight (IBW)
Current meds: drug name, strength, route, frequency, duration

Question 7

Assessment

Answer 7

Problems: Identify and prioritize, assess and justify using subjective and objective info, clinical rational and literature (guidelines, trials)
Therapies: current therapies related to problem and goals, prospective drug review

Question 8

Plan

Answer 8

Prioritize the same as assessment
drug therapy recommendations: agent, route, dose, frequency, duration
stopping/changing/continuing meds
monitoring plan
counseling/pt education
follow-up

Question 9

Prospective Drug Review

Answer 9

Drug therapy problems: drug-allergy, drug-drug, drug-disease interactions, unnecessary drug therapy (therapeutic duplication, drug w/o indication), incorrect dosage/duration, over/under utilization, indication w/o drug, clinical abuse/misuse, assessment of potential med related complaints (AEs), pt education/management, adherence