SOAP Notes–Comprehensive (2 pages)
S:
CC: [Concise statement of reason why patient is being in (use patient’s own words.]
HPI: [Use OLD CHART mnemonic and link to CC: Onset, Location, Duration, Character, Alleviating/aggravating factors, Radiation, Temporal pattern, symptoms associated]
PMH: [Full list of previously identified medical problems and if possible, date of diagnosis]
PSH: [Surgical procedures in past with date]
FH: [Include any medical history similar to patient’s diagnosis]
SH: [Occupation, living situation, level of education, exercise status. Include review of drugs of abuse/misuse here including alcohol, nicotine, caffeine, prescription drugs and illicit. Diet may be included here as well (low sodium, low fat) or may be included as its own section]
Meds: [Include prescription, OTC, herbals, vaccinations. Please include indication, start date (if known), adherence (if known). Consider using a table format for clarity.]
All: [Include medication, food and environmentals]
ROS:[Head to toe, eliciting any positive findings: weight gain/loss; rashes; headache; visual acuity;hearing; sinuses;throuat; mouth; chest pain; SOB; cough; palpitations; appetite; diarrhea, constipation, dysuria; urinary retention; bruising; pain anywhere; numbness; fever; anxiety; depression; sleep problems, etc. For any positive finding, do a further symptom analysis]
O:
Vital signs (Ht, Wt (acutal and IBW), BMI, RR, P, Temp)
PE (this is typically performed by prescriber, you will want to include pertinent positives that support assessment and plan]
LABS [List most recent labs with reference range, if there is one being monitored, show trend over time]
Diagnostic tests (EKG, UA, ECHO, CT, MRI, DXA, CXR, etc.)
A:[What you think the patient’s problem is based on subjective an d objective findings. Problem oriented, list in numerical order as diagnosis or differential diagnosis. All active problems should have an assessment and you should include all reasons for your assessment. Do NOT write this section in paragraph format, no rambling thoughts]
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SOAP Notes/Comprehensive
Page 2
P:[Corresponds with assessment. You must have a plan for each assessment made and the plan will follow the same numerical format as assessment. Plan may include ordering additional diagnostic tests or initiating, revising or discontinuing treatment. Provide rationale for specific changes made. List all medication changes with drug, dose, dosage form, schedule, route, and duration of therapy. Include clearly stated goals of therapy in this section – goals must be measurable. Include outline of efficacy and toxicity parameters used to determine if desired therapeutic outcome is being achieved and to detect drug-related ADRs.Do not write this is paragraph form and no rambling thoughts.]
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Parameter / Method / Frequency / Duration / Specific Goal / Alternate TherapyPatient Education (if requested)
Helpful References
American Pharmacists Association. (2007) Documenting Patient Care Services Module 5: Medication Therapy Management Services. Available online at Accessed April 14, 2011.
American Society of Health-System Pharmacists. ASHP guidelines on documenting pharmaceutical care in patient medical records. Am J Health-Syst Pharm 2003;60:705-707.
Canaday BR, Yarborough PC, Malone RM, Ives TJ. (2009). Documentation of Pharmacotherapy Interventions. In Schwinghammer TL, Koehler JM (Eds.),Pharmacotherapy Casebook: A Patient-Focused Approach(pp. 29-35). New York, NY. McGraw Hill Medical. (This is available through Access Pharmacy through the ACP link)
Schwinghammer TL. (2009). Care Planning: A Component of the Patient Care Process. In Schwinghammer TL, Koehler JM (Eds.),Pharmacotherapy Casebook: A Patient-Focused Approach(pp. 21-28). New York, NY. McGraw Hill Medical. (This is available through Access Pharmacy through the ACP link)
Sierler-Brown S, Brown TR, Chen D, et al. Clinical documentation for patient care: models, concepts, and liability considerations for pharmacists. Am J Health-Syst Pharm 2007;(65(1): 1851-1858.