Pharmacy Skills Laboratory Guide to Writing a SOAP Note

General Comments
Why should pharmacists write SOAP notes?
• To document and communi-cate medication and health-related needs between phar-macists and with other health care
providers.

The pharmacy care plan is a useful and required documentation tool for pharmacists, as it facilitates
continuity of care for patient. However, it is not always necessary to communicate all the information
presented in the pharmacy care to other health care providers. The pharmacist must use his or her discretion
to decide what information should be communicated. A SOAP note is one documentation format that is
commonly used for documenting in-patient charts, in the institutional setting. It uses the problem-oriented
approach to documentation, where S = Subjective information, O = Objective patient information, A =
Assessment of the problem (i.e., your Thought Process) and P = plan of how the problem will be addressed
and when follow-up will occur.

• The SOAP format is used by pharmacists primarily to communicate written patient

information in the medical record.
o (S)ubjective, (O)bjective, (A)ssessment, (P)lan

• The (S)ubjective and (O)bjective information in a SOAP note should be limited to only that
information which pertains directly to the (A)ssessment or recommended (P)lan.

• (S)ubjective information is obtained verbally(orally) from the patient or care giver

and so is not directly observed or measured by the SOAP writer.
o Information in this section can come from the following sections of the medical
record:
 Chief Complaint (CC)
 History of Present Illness (HPI)
 Past Medical History (PMH)
 Social History (SH)
 Family History (FH)
 Medication History (prior to admission)

• (O)bjective information is presented next, and details data directly measured or observed
by the SOAP writer or another health care professional.
o Information for this section includes:
 A general description of the patient
 Vital signs
 Physical exam findings
 Results of diagnostic testing and imaging (e.g. x-rays, CT/MRI, EKG, EEG)
  Laboratory results
 Current drug therapy (from profile or chart)
 Drug allergies or adverse reactions
• The (A)ssessment section communicates the critical thinking of the writer. A pharmacist’s
assessment is drug- related.

o A treatment goal should be specified for each problem and whether the goal has been met.
 For some diseases addition information should be included such as risk factors,
disease scores or other information that are used to determine a treatment goal.

o Discuss how the patient’s drug therapy conforms to standard, evidence-based drug
therapy recommendations.
 For example, discuss how well a patient’s currently therapy matches JNC7
(hypertension), NCEP ATP-III (cholesterol), or NIH (asthma) treatment guidelines.
 Consider patient factors such as medication adherence and financial considerations

o It should identify drug-related problems (DRP) and explain why they need correcting.
 DRPs can be roughly categorized into categories
• Current drug therapy
o dose not optimal
o not receiving optimal drug
o experiencing adverse drug reaction
o experiencing unwanted drug interaction
• Missing drug therapy
o not receiving a drug needed for optimal therapy

o It should also include is a short list of therapeutic alternatives with a brief

explanation of benefits and potential problems associated with each option, and
treatment goals.

o When written optimally, by the time the reader reaches the end of the assessment section,
that reader will know exactly what is going to be recommended, and why.
*The (P)lan communicates to other providers specific recommendations regarding the patient’s drug
therapy or other actions needed to facility treatment.

o Recommendations may include

 Drug Therapy Changes
• New drug therapy
o recommend drug name, dose, route, frequency, and duration
• Altered drug therapy
o specify which drug to change and the new dose, frequency, and duration
and how quickly the change is to occur (e.g. immediately or tapered)
• Discontinued drug therapy
o specify which drug(s) are be discontinued and when (e.g. immediately to
tapered)

*Common Documentation Mistakes

1. Information in the wrong place
2. Vague or unclear information
3. Excluding important information (which results in an unsupported (A) assessment statement)
4. Including extraneous information (including information which doesn’t directly
support the (A)assessments makes a note that is too long)
5. Lack of clear reasoning supporting choice of recommendation in (A)assessment (e.g. no
treatment goals, discussion of treatment guidelines, etc.)
Inaccurate or incomplete problem assessment, drug therapy recommendations, or monitoring planThe
following provides an example of a SOAP note using Patient Walsh as an example.

S:
Mrs. Walsh has been concerned about developing osteoporosis since many of her friends have been diagnosed
with osteoporosis. She is eight years postmenopausal, has never taken calcium supplements and her diet
provides her with negligible ( diabaikan) amount of elemental calcium. She does not like to take milk
products, although she does take a multiple vitamin that provides her with vitamin D 400IU. She does not
have a family history of osteoporosis and has an active lifestyle, which consists of gardening and golfing in the
summer, and two miles every day in the winter. She mentioned that she has never discussed osteoporosis with
her physician, has never had a bone density (kepadatan) done and has never been on hormone replacement
therapy.

O:
She is a 65 years old Caucasian female of small build. She is not on any medications that can increase
her risk of osteoporosis.
A:
Mrs. Walsh’s calcium intake is significantly lower than what is suggested by the guidelines for prevention
of osteoporosis (1.5g per day). This puts her at an increased risk of developing osteoporosis, and she
would benefit from additional calcium supplementation.
P:
• Calcium carbonate 600mg twice daily (breakfast & supper)
• Provide a sheet summarizing calcium content of various foods. If Mrs. Walsh diet should
change to include these food groups, her dose of calcium should be adjusted.
• Provide a pamphlet discussing osteoporosis
• Have Mrs. Walsh make an appointment for tomorrow to: 1) discuss osteoporosis and, if
necessary, refer her to her physician for further evaluation, and 2) discuss her falls and Valium use
• Recommend that she continue with her exercise program.
F/U: Have patient call pharmacist in two weeks to reevaluate the plan based on the monitoring
parameters discussed.

Student SOAP Example #1

Pharmacy note regarding CAD medication therapy for 56 male
S: Pt here today for follow up of lipids after starting simvastatin 20mg 6 weeks ago. He reports that he tries to take his
medication every day, but sometimes forgets. He has not had lipids checked since starting the stating. Denies side effects.
Reports that he has tried to avoid eating eggs and that he frequently walks because his main form of transportation is the bus
and walking is required to and from bus stops. Pt re-ports that he will have a treadmill test next week. Pt states that he takes
aspirin 325mg po daily most days. After taking blood pressure, pt stated that he took blood pressure medication in the past. Pt
currently homeless. Continues to deny alcohol use

O: Current meds: simvastatin 20mg po daily, aspirin 325mg po daily

BP today 140/95

A: Blood lipids have not been checked since pt started taking stating, will want them checked before titrat-ing dose. Current
stating is expensive, will change patient to lovastatin as he is uninsured. Homeless— difficult to contact, may be difficult for
him to make good diet choices. BP was a bit elevated today— continue to monitor but may need to address at future visit. Pt
currently buys his own aspirin, taking 325 mg po daily. Will provide rx here at clinic to decrease med cost.
P:
Hyperlipidemia. Gave pt lab slip to check lipids today. Changed pt to lovastatin 40mg po daily to de-crease
medication cost. Will f/u with pt next Thursday.
Blood pressure: Check at f/u appt on Thursday
Other: Provided rx for aspirin 81mg po daily to pt to be filled here.
Student SOAP Example #2
Pharmacy note regarding anemia

S: 42 yo woman presents with pale skin, weakness, dizziness, and epigastric pain. 2 weeks ago she expe-
rienced decreased exercise tolerance. She takes frequent doses of antacids and uses ibuprofen 00mg prn
headaches. NKDA. She has children age 15, 12, and 1.
O: T 38 C, RR 18, BP: sitting 118/75, standing 120/60, HR: Sitting 90, standing 110. Hb 8gm/dL, Hct 27%, platelets
300,000/mm3, retics 0.2%, MCV 75, serum iron 40mcg/dL, serum ferritin 9ng/ml, TIBC 450 mcg/dL, guaiac stools.
Cheilosis at corners of mouth, and koilonychias at nail beds. PMH: peptic ul-cer and pre-eclampisa with last
pregnancy. Dx: iron-deficiency anemia.
A:

p Fe: counsel parent on tolerance and side effects.

q Discuss guaiac stool and ibuprofen, f/u with PCP on GI bleed, possible ulcer. d/c ibuprofen, use APAP
prn HA.
P:

• Iron sulfate 325mg TID x 6 months – f/u with PCP for retic count after 7 days of therapy. coun-
sel/educate patient on a) take on empty stomach if possible, ok with food if cannot tolerate, b) separate iron
dose from antacid dose, c) iron can cause constipation and darken stool color, d) keep iron out of reach
from children – toxic.
• Make appt with pcp for probably ulcer/GI bleed. d/c ibuprofen, take acetaminophen 500mg po q 4-6 h
prn p, NTE 4000mg/24 h (counsel on liver toxicity)