Objectives

• List the components of a SOAP note

• Explain the elements within each component of a SOAP note

• Identify where specific patient information should be placed within a SOAP note

• Apply SOAP note principle to document a patient encounter

SOAP Notes & Progress Notes

• Purposes of documentation

• Improving patient care & outcomes

• Providing patients with information about their care

• Enhancing continuity of care

• Ensuring compliance with laws & regulations

• Protecting against professional liability

• Creating a record of services provided for billing & reimbursement

• Establishing the pharmacist’s credibility as a healthcare provider

• __S__ubjective

• Information provided by the patient, family, or caregiver

• Thorough, but concise

• Descriptive and cannot be measured directly

• Chief complaint (CC) - in patient’s own words

• Usually provided in quotes

• May not always provide a specific complaint

• History of present illness (HPI)

• Initials, age, race, gender

• Further description of patient’s complaint

• SCHOLAR

• May not have complaints

• Past medical history (PMH)

• Complete listing of childhood & adult illnesses

• Includes diagnosis

• Ideally include duration/year of diagnosis

• May include surgical history

• Family history (FH)

• Include FH of first-degree relatives only

• Mother, father, siblings, and children

• If FH does not impact therapy decision, can write as non-contributory

• If unknown, can document as such

• Social history (SH)

• Health/lifestyle

• Exercise

• Diet

• Alcohol intake

• Tobacco

• Illicit drugs

• Living situation

• Occupation

• Insurance

• Positive/negative use

• Quantify how much

• Medications

• All prescriptions, OTC, herbals/supps

• Include:

• Name

• Strength

• Route

• Frequency

• Duration

• Allergies

• What is the allergy & reaction?

• When did this occur?

• If none, write NKDA

• Immunizations

• Include immunizations that the patient has received and the year it was given

• Review of systems

• Set of questions asked that pertain to symptoms associated with each body system

• Will indicate the body system, symptom asked, and which are positive vs. those that the patient denies

• If not performed, can document as “deferred” or “not performed”

• __O__bjective

• Data obtained by the clinician, EMR, Lab work, and diagnostic tests

• Can be measured

• Should only include the pertinent positive and negative findings

• Vital signs

• BP, HR, RR, temp, height, weight, BMI

• Physical exam

• Includes pertinent observations & results of any physical exams

• Broken down by organ system

• Head, ears, eyes, nose, throat (HEENT)

• Neck

• Chest

• Heart

• Abdomen

• Musculoskeletal

• Extremities

• Skin

• CNS

• If not performed, can document as “deferred” or “not performed”

• Laboratory tests

• Includes pertinent lab values for the patient such as Basic Metabolic Panel (BMP) or Complete Blood Count (CBC)

• May also include additional labs such as:

• Lipid panel

• Blood glucose

• Hemoglobin A1C

• Pregnancy test

• Often compared to previous values to show trends of increasing or decreasing values

• If all normal values, may document as WNL (within normal limits)

• Serum drug concentrations

• Include results for drugs that require blood drug monitoring such as vancomycin, phenytoin, valproic acid

• Include target or goal levels

• Diagnostic tests

• Broad spectrum of diagnostic tests such as EKG, X-rays, blood cultures

• May be the actual image or an interpretation of what was seen

• Problem List

• Prioritized by importance

• Problems are numbered

• Problems can be defined by:

• Patient concern/complaint

• Provider concern

• Disease that has not been diagnosed or treated

• Abnormal lab test/exam finding

• Social or financial situation

• Drug therapy problem

• Includes all medical problems, even if controlled

• Usually falls between objective and assessment sections

• __A__ssessment

• Outlines what the practitioner thinks the patient’s problem is based on subjective and objective information

• Includes active problems (including problems which are controlled)

• Helps other healthcare providers reading the note to understand how the clinician arrived at their assessment

• Disease assessment (supporting evidence)

• Often includes severity or current status of a disease state

• Includes evidence to support practitioner’s thinking

• May also include potential causes

• Goals

• Clear, achievable, and measurable

• May be short- or long-term goals

• Refer to treatment guidelines from national organizations

• Can include functioning, survival, or event prevention

• __P__lan

• Includes actions needed to resolve the identified problems

• Pharmacologic

• Provide a complete description of the drug recommendation

• Drug

• Dose (calculate if weight-based)

• Route of admin

• Frequency

• Duration of therapy (not always known)

• Do not always need to change medication

• Non-pharmacologic

• Lifestyle modification

• Involve patient in development

• Do not always need to change here, but can encourage current routine

• Avoid duplication of content among the plan sections

• Education & counseling

• Briefly mention most important counseling points that should be communicated to the patient for each problem & treatment

• Remember DI resources

• Include details of non-pharm recommendations above

• Include counseling for side effects of medications

• Monitoring & Follow-Up

• Include what is to be measured, how often, and where the patient should go to have this measured

• Include monitoring for efficacy and safety

• Efficacy = is the treatment plan working?

• Safety = is the patient experiencing any side effects?

• Rationale

• Discuss your thought process for the treatment choice

• Recommendations should be evidence-based

• Reference disease state guidelines

• State why or how guideline recommendation applies to the patient

• State why or how the medication will help treat the condition (ex. Mechanism of action)

Helpful Tips

• DO

• Be specific & make a complete recommendation

• Take ownership of the patient’s care (plan should not be “referral to physician” for every problem)

• Be brief & concise

• Use descriptive terms including med terminology

• Document immediately after (or during) each session

• Start each note with date & time

• End each note with a signature including your title

• Abbreviate as much as possible

• DON’T

• Avoid duplicating information

• Avoid vague recommendations

• Avoid listing multiple treatment options – pick one!

• Avoid unapproved abbreviations

• Avoid using judgmental words to describe a patient (ex. stubborn, lazy) or a medication (inappropriate, wrong, senseless)

Practice Notes

• Subjective

• CC: “I am here to have my blood pressure checked again and see if I need any new medicine”

• HPI: follow-up after receiving a screening at ONU Healthwise mobile clinic on 8/19/22. Pt said BP was “a little high” that day. Referred here for BP management

• PMH: high blood pressure

• FH: mother - (deceased) heart attack at 50 yo, healthy father, healthy siblings

• SH: eating out 1-2 times per week, cup of coffee & can of soda q day; walk 2-3 times q week; no cigs or nic; no drugs; 1-2 beers q weekend; no cost issues, no insurance issues

• Meds: Lisinopril 10 mg po qhs; Tylenol for headaches 1-2 times q month; no herbals

• Allergies: NKDA

• Immunizations: Pfizer covid Vaccine 6/22, flu shot 10/21

• ROS: deferred

• Objective

• Vital signs:                 BP: 116/70        (Goal = < 130/80)

• HR: 78                        (Normal: 60-100)

• RR: 16                 (Normal: 16-20)

• Temp: 98.6

• Ht: 5’11’”

• Wt (kg): 100 kg

• BMI: 30.7

• Physical exam: deferred

• Labs: WNL

• Problem List

• Hypertension (#1)

• Occasional headaches

• Assessment

• Disease assessment: controlled HTN (116/70)

• Goals: Maintain BP < 130/80; reduce overall lifetime risk of heart attack and stroke

• Plan

• Pharmacologic

• Continue Lisinopril 10 mg qhs

• Non-pharmacologic

• Continue exercise 2-3 times weekly & keep eating out to 1-2 times per week; cut back on caffeine to 1 cup of coffee or 1 soda per day

• Education & counseling

• Lisinopril may cause cough

• Monitoring & follow-up

• Follow up with pharmacist in 3 months to re-check patient’s BP

Physical Assessment & Abbreviations in Progress Notes

• O of SOAP notes

• Physical exam

• Includes pertinent observations & results of physical exams

• Typically start at the top and move down:

• HEENT (head, ears, eyes, nose, throat)

• Neck

• Lungs

• Heart

• Abdomen

• Genitourinary

• Rectal

• Musculoskeletal & extremities

• Skin

• Neurologic

• If not performed, may document as “deferred” or “not performed”

• Inspection: general observation of patient

• Palpation: use of the sense of touch in the evaluation of the patient

• Percussion: used to produce sounds, elicit tenderness, or assess reflexes in a patient

• Auscultation: involves listening for normal and abnormal sounds with a stethoscope

• Diagnostic tests

• Broad array of tests

• May be the actual image of an organ or an interpretation of what was seen

• Imaging tests (ex. x-ray, MRI)

• Electrophysiology (ex. EKG, EEG)

• Screening results (ex. blood cultures)

• Risk calculations (ex. 10 yr ASCVD risk)

HEENT

• Physical exams may include:

• Head: Hair, scalp, skull, face, skin

• Eyes: general inspection, reactivity of pupils, ophthalmoscopy, extraocular muscles

• Ears: internal inspection, otoscopy

• Nose: external inspection/palpation, otoscope

• Throat/neck: inspection of mouth & pharynx, palpation of lymph nodes & glands

• Abbreviations

• NCAT = Normocephalic atraumatic

• PERRLA = pupils equal, round, and reactive to light and accommodation

• EOMI = extraocular muscles intact

• Imaging

• Can visualize a stroke, tumors, blood flow, etc.

• EEG (electroencephalogram)

• Measures the electrical activity of the brain

CHEST, HEART, LUNGS

• Physical exam: inspection, palpation, and auscultation

• Dyspnea (labored breathing)

• Breath sounds

• Cough & sputum

• Chest pain

• Palpitations

• Abbreviations

• RRR = regular rate & rhythm

• Chest radiograph (CXR): very common when evaluating lung conditions

• Consolidation: areas of the lung where air should be, but it is not

• Replaced with fluid, pus, and/or blood

• Infiltrate: dead cell, debris, pus commonly seen with pneumonia

• Atelectasis: partially or fully collapsed lung

• Pleural effusion: fluid in the space between the chest wall and lungs

• Aspiration: inhalation of food particles or stomach contents

• Computed tomography (CT) scan

• May be done as a follow-up scan to a CXR

• Provides better detail than a standard x-ray

• Can assess for pulmonary embolism, lung masses, internal bleeding, or edema

• May require administration of IV contrasts

• “Echo”: echocardiogram

• Ultrasound of the heart

• Provides information about the size, shape, and pumping ability of the heart, as well as visualization of the heart valves

• EKG or ECG: electrocardiogram

• Measures electrical activity of the heart

• Can show heart rate & rhythm

• Can show parts of the heart that are too large or overworked

• Cardiac catheterization

• “Going to the cath lab”

• Procedure to look for disease in the heart muscle, valves, or coronary arteries

• Coronary angiography: contrast dye is injected through a catheter. X-ray images show the dye as it flows through the heart arteries. This shows if the arteries are open or blocked

• Angioplasty or percutaneous coronary intervention (PCI): when a catheter is used to clear a narrowed or blocked artery or a cardiac stent is placed

• Pulmonary function test (PFT)

• Spirometry

• Measure of lung volumes, useful in asthma and COPD

• FEV1: forced expiratory volume in 1 second

• FVC: forced vital capacity

ABDOMEN/GI

• Physical exam: assess the four quadrants of the abdomen

• Inspection: color, texture, vascularity, contour

• Auscultation: bowel sounds, vascular sounds

• Percussion: fluid, gaseous distention, and masses

• Palpation: areas of tenderness, muscle spasms, or the presence of fluid or masses

• Esophagogastroduodenoscopy (EGD)

• Endoscopic procedure that examines the esophagus, stomach, and duodenum (part of small intestine)

• May help locate a GI bleed

• Biopsy may also be done at the same time

LOWER EXTREM.

• Physical exam

• Leg pain, skin abnormalities, edema, hair growth, nails

• Palpate pulses in extremities

• Evaluate joint rotation and reflexes

• Doppler ultrasound

• Quick way to check for problems with blood flow

• DVT: deep vein thrombosis

Microbiology

• There can be many sources of infection in a patient

• Urine → UTI

• Lungs → pneumonia

• Skin → cellulitis

• We often start antibiotics to help with the infection before we know what bacteria is growing → empiric coverage

• A sample is collected from the source of the infection and sent to the microbiology lab

• They culture it to see what bacteria grows and what antibiotics are most effective in killing it/inhibiting its growth

• Antimicrobial stewardship = improve how antibiotics are prescribed by clinicians and used by patients

• Based on microbiology reports

• S = sensitive

• bacteria will be killed by antibiotic

• R = resistant

• bacteria will not be killed by antibiotic