SOAP notes

A method for medical record documentation

1. SOAP notes Patient medical documentation Made by: Abdurahman Salah Ali [email protected]

2. Medical record [1] Medical record is a form of documentation for the patient made by health care staff usually nurses and clinical pharmacists written in a clear language and standard format and should include: Patient history Consultations to other health care team Drug orders Drug adjustments (dose, dosage form, time, frequency) Drug-related problems Monitoring Resolution plan

3. Importance: A better way for communication among the medical staff. A better way for communication between healthcare organizations. Help in education and research. Avoid the most of human mistakes in prescribing. Can help decrease time waste specially if automated. Formal and organized.

4. SOAP notes [1] SOAP notes is a type of patient medical record documentation in which S stands for subjective O stands for objective A for assessment and P for plan. [2] A . Subjective: (non measurable)descriptive information of the problem or the reason of the encounter reported by the patient including history of past medication etiology of the disease, past illness, and social life cannot be confirmed by procedures or diagnostic tests.

5. B . Objective: (measurable) done by the medical team and includes intervention of physicians and medical equipment summarized by values and numbers by which a proper diagnosis can be established. C . Assessment: is the summation of subjective and objective data includes conclusion and differential diagnosis and the reason for this diagnosis. D. plan: the final step which includes drugs (maintained or changed), patient follow up, monitoring, and counselling

6. A. Subjective [3] Includes: History of the past illness History of present illness History of drugs: taken and stopped Social history: alcohol, tobacco, economic status, and occupation Diet Review of systems Drug and food allergies Chief complaint

7. where to collect these information: Patient himself Caregiver Family Past PMR (if found) The community pharmacy that the patient deals with Prescriptions patient’s own medicines Other health organizations (private hospitals, clinics,…)

8. B. Objective [3] Includes: 1. Physical examination : in which the physician tries to find any sign of the potential disease or any other illness. (palpation, percussion, auscultation, inspection, and neurological examination) [4] 2. Diagnostic tests : like x-ray, CT scan, MRI, ECG, endoscopy and usually describes what can’t be seen with the naked eyes.

9. 3. Lab values: [5] valuable tools that may be used to gain additional information about the patient.(not therapeutic) they can be used to differentiate among possible diagnoses, confirm a diagnosis, assess current status, or evaluate response to therapy when history and physical exam alone cannot. Selection of laboratory tests is based on clinical judgment, with evidence-based medicine used to guide these decisions. Reproducible measurable In all laboratory tests a specimen is taken from the patient. examples: renal function tests (creatinine, alb ), liver function tests (AST, ALT), lipid profile (LDL, HDL, TG)

10. 4. Serum drug concentration: [1] Aid in confirming actual and potential adverse drug reactions, toxic dose, and drug efficacy. 5. Vital signs :[1] Blood pressure (BP), pulse(P), temp(T), respiratory rate(RR)

11. C. Assessment [6] In which the clinical pharmacist cooperate with the physician to achieve the best treatment. Diagnosis or differential diagnosis Identification of Dose regimens problems Identification of drug-drug interactions Identification of drug-food interaction

12. Drug safety and efficacy Additional drugs requirements Patient compliance Identification of drug-disease interactions May order other diagnostic or laboratory tests to confirm a diagnosis

13. D. Plan It should be: 1. Achievable 2. Each drug should be compatible with each other 3. the least side effects 4. Safe and economic drugs 5. achieve definite outcomes 6. compatible with the compliance of the patient( the least number of doses) Includes: Treatment plan Patient education Follow up Monitoring

14. Monitoring [6] : Many drugs, due to its low therapeutic index, needs TDM which in a fairly lower dose can be ineffective or toxic in case of increasing the dose like antiarrhythmic drugs (lignocaine), cytotoxic drugs(methotrexate), or anticonvulsants. Steps: Collection of patient data Statement of therapeutic goals Selection of medication Establishing of monitoring parameters Identification of resolution problems

15. Patient education [6] : Help the patient to be fully understanding of his illness and most compliant to medication therapy and it’s about: Actual and potential adverse drug reactions. Time, frequency, and route of the dose Etiology and prognosis of his disease How to administer a drug device

16. Follow up [6] : Aids in achievement of best compliance of the patient and best outcomes and resolution. Determine actual outcomes of therapy for the patient and comparing it with suspected outcomes in which: 1. determine efficacy and safety of the therapy 2. evaluate adherence 3. establish the current status of the patient’s medical condition 4. help increase learningand knowledge of the practitioner

17. References McCarthy, Michelle w. (n.d.). clinical pharmacy skills. In  oxford American handbook of clinical pharmacy  (pp. 34–53). Newyork , Newyork : oxford university press Inc. Timothy, J. I., Bruce, R. C. D., & Peggy, C. Y. (n.d.). Documentation of Pharmacist Interventions. In  Instructor's Guide to accompany Pharmacotherapy Casebook  (5th ed., pp. 99–104). College of Pharmacy Standardized SOAP note, Rubric, &expected components. (2017, November).  Oregon State University . chemocare.com/chemotherapy/before-and-after/the-physical-examination-and-health-assessment.aspx Warburton, J., & Beale, L. (n.d.). General/laboratory data. In  clinical pharmacy and therapeutics  (6th ed., pp. 81–102). Elsevier. Suzan, M. S. (n.d.). Clinical Drug Monitoring. In  Boh’s Pharmacy Practice Manual: A Guide to the Clinical Experience  (4th ed.). Philadelphia: Lippincott Williams & Wilkins.