IPPE 5 - SOAP Note Writing (Textbook Chapter 6)

Chapter 6 - SOAP NoteWriting

Something worth thinking about• Pharmacists are the only health careprofessionals who do not routinelydocument their patient careactivities.• Most pharmacy records areadministrative or billing records, notpatient care records.

Organize the data• Subjective data:• Objective data:• Cannot be• Can be measuredmeasured directly• Are observable or• May not bereproducibleaccurate or• Are often numericalreproducible• E.g., Taking a• Usually supplied bypatient’s s bloodthe patientpressure and• E.g., “I I have highlearning it isblood pressure.”” 126/82

Objective but incomplete• Medication history consisting only ofthe information in the pharmacycomputer does not include:• Samples• OTC’s• Rx filled elsewhere• Borrowed medications• Herbals, nutritionals

Finally• Pharmacists frequently do not haveany objective information to report.Not every SOAP note will haveobjective information in it• Only relevant data need bedocumented• Verify with your faculty to see howthey want you to consider anddocument data - especially drughistory (S or O?)

The SOAP note• Subjective - includes only relevantsubjective data• Objective - includes only relevantobjective data• Assessment - describes conclusionsabout the patient (what’s s his DTP?)• Plan - who needs to do what next,when and how they will do it,monitoring plan

Common problems with SOAPnotes• Subjective contains information that’s s notsubjective (same with objective)• Not enough information in the S/O tosupport A - it should be obvious to thereader why you concluded what you did• DTP not included in A and re-phrased aspatient problem (e.g., dose of Norvasc toohigh - patient at risk for fall)

Common problems with SOAPnotes• Too much or irrelevant information in S/Othat slows down the reader• New information being introduced in theassessment or plan• No follow-up or monitoring plan included• Monitoring plan is included, but is vagueor non-specific (e.g., ‘follow up in 1 week’)

Documentation checklist• See pp. 145, 148, and 150-1 1 of thetext book (3rd edition) for moredetail on documentation checklist

Subjective section• Date• Patient identifier• Patient DOB• CC• HPI• PMH• SH• FH• Allergies• Previous ADRs• ROS• Medication historyand how patient istaking (if not in O)

Objective section• Objective measures such as• Vitals, lab tests, physical exams,screening tests• Include the source of the measure• E.g., “BP as per Dr. Cowan 136/92” or“blood sugar in pharmacy 210 mg/dl”• Medication history and how patient istaking (if not in S)

Assessment section• Describes the DTP and the patient’sproblem. (If not in the note’s s title)• If a follow up note, includes thestatus of the problem (stable,improved, worsening, resolved)• May need some explanation of theDTP• Goal for therapy can be documentedhere

Plan section• How will the DTP be resolved? Whowill do what to resolve it? When?How?• MUST include a follow-up ormonitoring section• Goal for therapy can be documentedhere if not in A

Some tips• Keep your note SHORT and TO THEPOINT• Most initial notes usually ≤ 1 page• Follow-up notes usually shorter thaninitial notes• Don’t t include information that doesnot assist in decision making

What’s s wrong with thefollowing?• S: Mrs. RG is a 76-yryr-old womanwith 5 grandchildren. She comesinto the pharmacy requesting OTCtreatment for a history of osteo-arthritis x 2yrs. She claims a historyof aspirin allergy (GI upset). PMHincludes OA, GERD, HBP andelevated TC• (includes irrelevant information - 5grandchildren)

What’s s wrong with thefollowing?• O: Medication history includesNorvasc 10 mg qd for BP, Nexium 20mg qhs for GERD and Pravachol 20mg qd for elevated TC. Cholesterol165 mg/dl as per physician office• (history is incomplete - includes onlyprescription medications filled in thispharmacy)

What’s s wrong with thefollowing?• A: Dose of APAP too low for OA.Patient requires symptomatic painrelief for OA pain. Has tried Tylenol500 mg tid in past with little relief• (introduces new information in theAssessment that should be in S or O -use of Tylenol)

What’s s wrong with thefollowing?• P: Recommended pt increase APAPto 1 g po qid scheduled dose.Patient agrees• (missing follow-up and monitoring plan)