How To Write a SOAP Note
By: Minimalist, Pharmacist, Admin
Tags: Healthcare, Naplex, Pharmacy, Guest Post, Doctors

SOAPE Note Guidelines

Subjective:

History of present illness

Past medical history

Home medications

Pertinent Social History

Pertinent Family History

Pertinent psychosocial issues (e.g. compliance, level of education, literacy)

Objective:

Vital signs

Pertinent lab values

Arrange by organ system, working from head to toe

Current medications

Dose

Route

Frequency

Assessment:

Prioritized problem list

Match the patient’s current medications to the appropriate indication

Detail any drug related problems

The patient needs a drug . This could be because the drug hasn’t been prescribed or because it has been prescribed but the patient isn’t taking it.

. This could be because the drug hasn’t been prescribed or because it has been prescribed but the patient isn’t taking it. The patient is not receiving the optimal drug . This includes instances where the drug being used is not appropriate. It also includes situations where the drug being used is appropriate but another therapy may produce superior health outcomes.

. This includes instances where the drug being used is not appropriate. It also includes situations where the drug being used is appropriate but another therapy may produce superior health outcomes. The drug dose is not optimal (e.g., too high, too low, too frequent).

(e.g., too high, too low, too frequent). The patient is experiencing an adverse drug reaction .

. The patient is experiencing an unwanted drug interaction .

. Detail any disease related problems

Goal of therapy

Where does this goal come from?

Has patient achieved goal? Why or why not?

Plan:

Work off of prioritized problem list from assessment

Suggest medication therapy changes and give the reasoning for your suggestion

What is the evidence base or guideline which supports your plan?

Suggest any lab work or monitoring parameters you would like to add. Be specific, what and when?

Education:

Key education points for the patient

Disease state knowledge

Patient specific monitoring parameters

Administration guidelines

Adverse effects

Lifestyle modifications/teaching

Drug interactions

Address any necessary psychosocial issues

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