SOAP powerpoint

Question 1

What are the best sources for clinical information?

The __________
Medical record
Family members or others who assist with the
patient’s care
The patient’s physician, nurse, social worker,
and therapists (e.g. physical therapist)
Pharmacists who care for the patient

Answer 1

patient

Question 2

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

Question 3

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

Question 4

Patient History

Standardized format helps ensure information is complete

Information outlined in a clear, concise, and predictable manner

Facilitates communication among other health care professionals

Same format used for “Patient Presentation” (USE the pocket guide)

Question 5

_______________ (CC)

Answer 5

Chief complaint

Question 6

_____________ (HPI)

Answer 6

History of present illness

Question 7

____________ (PMH)

Answer 7

Past Medical History

Question 8

_______________(DH)

Answer 8

Drug history

Question 9

____________ (FH)

Answer 9

Family history

Question 10

___________(SH)

Answer 10

Social history

Question 11

_______________ (ROS)

Answer 11

review of systems

Question 12

SCHOLAR-MAC
Symptoms: What are main and associated
sxs?
Characteristics: What are the symptoms like?
History: Done so far? Happened before?
Onset: When did particular problem start?
Location: Where is the problem?
Aggravating factors: What makes it worse?
Remitting factors: What makes it better

Question 13

SCHOLAR-MAC

Medications: rx and non-rx, natural, herbals,
generic
Allergies: medication and other with reaction
Conditions: other medical conditions

Question 14

Why are we writing SOAP notes?
Patients have drug-related problems
Physicians have questions
Document, document, document!
Write a note with purpose! Be an agent of change! Your role is to consult as a pharmacist to care for patients and promote your profession.

Question 15

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
Counseling
SOAP

PHARMACIST’S assessment

Question 16

SOAP Note Format

Subjective (refer to handout)
Objective (refer to handout)

Medications and allergies should be listed in subjective or objective depending on the source of information

Question 17

SOAP Note Format
Assessment: 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

Question 18

Plan: 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, wks, mths, yrs???

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

Question 19

__________ – anything the patient tells you + ROS

Answer 19

Subjective

Question 20

The ORDER of Subjective

Chief Complaint (CC) – if you have it
History of Present Illness (HPI) – age and race
Past Medical History (PMH) – medical terms
Family History (FH) – medical terms
Social History (SH) – tobacco, alcohol, marijuana,
family, work, etc
Review of Systems (ROS) – head to toe (see pocket
card)
+/- Medication list

Question 21

Medication List

Generic names ALWAYS
Brand name may be in parentheses
Example: metoprolol succinate (Toprol XL)
Drug dose route frequency ALWAYS
Lisinopril 5mg po daily
ISMP appropriate abbreviations!!! NO QD NO SQ