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This document provides guidance on creating SOAP notes for patient encounters. It explains the components of the SOAP note format: Subjective (S) involves collecting information from the patient; Objective (O) includes physical exam findings and diagnostic results; Assessment (A) is the healthcare provider's analysis; and Plan (P) outlines the treatment plan. Each section of the SOAP note is described in detail, from collecting a patient's chief complaint and medical history in S, to conducting a physical exam and reviewing systems in O, to determining diagnoses or differential diagnoses in A, to developing treatment goals and interventions in P.

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30 views

Soap 1

This document provides guidance on creating SOAP notes for patient encounters. It explains the components of the SOAP note format: Subjective (S) involves collecting information from the patient; Objective (O) includes physical exam findings and diagnostic results; Assessment (A) is the healthcare provider's analysis; and Plan (P) outlines the treatment plan. Each section of the SOAP note is described in detail, from collecting a patient's chief complaint and medical history in S, to conducting a physical exam and reviewing systems in O, to determining diagnoses or differential diagnoses in A, to developing treatment goals and interventions in P.

Uploaded by

sannnnrwa8
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Pharmacology and Therapeutics I

Tutorials

Orientation session
PHARMACY PRACTICE
AASTMT
2021/2022
According to the American Pharmacists Association (APhA):

the mission of the pharmacy profession is to serve society as the profession


responsible for the appropriate use of medications, devices, and services to
achieve optimal therapeutic outcomes.
S = Subjective:
Why the patient is being seen?
Subjective information is descriptive and generally
cannot be confirmed by diagnostic tests or
procedures.
Much of the subjective information is obtained by
speaking with the patient while obtaining the
medical history.
S = Subjective:
 Chief complaint (CP).
 History of present illness (HPI).
 Past Medical History. (PMH)
 Medication or Drug history.
 Patient’s Information.
 Family History (FM).
 Social History (SH).
Subjective
1) Chief complaint:
The chief complaint (CC) is a brief statement of
the reason why the patient consulted the
physician, stated in the patient’s own words.

In the United Kingdom, the term “presenting


complaint” (PC) may be used.
Subjective
2) History of present illness (HPI):
A more complete description of the patient’s symptom(s), usually including:
 Date of onset
 Precise location
 Nature of onset, severity, and duration
 Presence of exacerbations and remissions
 Effect of any treatment given
 Relationship to other symptoms, bodily functions, or activities (eg; activity, meals)
 Degree of interference with daily activities
Subjective:
3) Past Medical History (PMH):
• Serious illnesses
• Surgical procedures
• Injuries the patient has experienced previously.

Minor complaints (eg, influenza, colds) are usually omitted unless they
might have a bearing on the current medical situation.
Subjective:
4) Medication History
Allergies and side effects (include the name of the medication and the reaction)
 Current prescription medications:
How the medication was prescribed.
How the patient is actually taking the medication.
Effectiveness and side effects of current medications.
Questions or concerns about current medications.
 Current nonprescription medications, vitamins, dietary supplements.
 Past prescription and nonprescription medications
(i.e., those discontinued within the past 6 months).
Subjective
5) Patient Information
 Demographics and background information:
 Age
 Gender
 Race
 Weight & Height
 Insurance/administrative information:
 Name of health plan
 Primary care physician.
Subjective
6) Social history:
 Living arrangements
 Occupation
 Special needs (eg, physical disabilities, cultural traits,
drug administration devices)
Subjective
7) Family history:
Relevant health histories of parents and siblings.
O = Objective:
Observable and measurable data that can be seen, heard or felt by
someone other than the one experiencing it.

Physical Examination.
Laboratory Findings.
Imaging and Radiological Findings.
Review of systems (ROS).
Objective
1) Physical examination:
“Head to Toe examination”
Gen General appearance
VS (Vital Signs) Blood pressure, pulse, respiratory rate, and temperature. In hospital
settings, the presence and severity of pain is included as “5th vital sign.”
Skin integumentary
HEENT Head, eyes, ears, nose, and throat
Lungs / Thorax Pulmonary
Cor / CV Cardiovascular
Abd Abdomen
Genit / Rect Genitalia - Rectal
MS / Ext Musculoskeletal - Extremities
Neuro Neurologic
Objective
2) Laboratory Findings:
Objective
3) Radiologic Findings:
Objective
4) Review of Systems (ROS):
In the review of systems, the examiner questions the patient about the presence of
symptoms related to each body system.
Objective
4) Review of Systems (ROS):
 In a complete ROS, body systems are generally listed starting from the head and
working toward the feet and may include the skin, head, eyes, ears, nose, mouth and
throat, neck, cardiovascular, respiratory, gastrointestinal, genitourinary, endocrine,
musculoskeletal, and neuropsychiatric systems.

 The purpose of the ROS is to evaluate the status of each body system and to
prevent omission of pertinent information.
A = Assessment:
 The assessment section outlines what the practitioner thinks the patient’s
problem is, based on the subjective and objective information acquired.

 Often takes the form of a diagnosis or differential diagnosis.

 This portion of the SOAP note should include all of the reasons for the
clinician’s assessment.

 This helps other healthcare providers reading the note to understand how the
clinician arrived at his or her particular assessment of the problem.
P = Plan:
Care planning involves establishing therapeutic goals and Determining
appropriate interventions to:

 Achieve the goals of therapy intended for each active medical problem.
 Resolve all existing drug therapy problems.
 Prevent future drug therapy problems that have a potential to develop.
Plan:
The plan includes:
 Initiating, revising, or discontinuing treatment.
 The rationale for the specific changes recommended should be
described
 The drug, dose, dosage form, schedule, route of administration
 Duration of therapy
 Additional diagnostic tests
Plan:
“The plan must be tailored to the
needs of each unique patient”

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