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SOAP Note
Date: XX/XX/XX
Time In: 10 AM
Pharmacotherapy Note:
S:
MM is a 51 YO CM who presented for follow-up regarding his diabetes selfmanagement education (DSME) and follow-up A1C testing. MM will begin group
support classes at the DERC in January. MM does not have PCP physician at this
time since he does not have insurance. He began a new job this month and
hopes to have insurance within the next 90 days. Patient does not report any
complaints today.
PmHx: Type 2 DM (since June 2009)
Melanoma on forehead
ALL: NKDA
CVD risk factors (-) tobacco (+) HTN (+)DM (+)Low HDL (-)FamHx Ht Dz (+)age
(M> 45, W>55) = 4 risk factors (1 CVD equivalent)
DM (-) polydipsia, polyphagia but has some increased urination last week when
starting his new job. Nocturia x 0-2. (-)episode(s) of hypoglycemia since last
visit. (+)tingling in wrist and calfs,(-) burning, and numbness of extremities or
cramping.
Pt reports (-)edema
HTN: (+)HA 2 days ago resolved with ibuprofen and rarely occurs (-) dizziness,
(-)chest pain. Trying to keep sodium intake <2g/d.
Trying to follow dietary recommendations: eating three meals a day. Has
already been in DSME part 1 and part 2 classes (carb counting) and is waiting to
join a support group.
Soc Hx: (-) Tob, (-) EToh, (-) illicit drugs, (+) caffeine (1 cup tea in AM with
skim milk and sugar subst), not exercising right now due to left toe amputation
in June. New position at different hotel, as an auditor on 11-7PM shift.
SurgHx: Left toe amputation
SMBG: per patient log (10/10-10/13): (FBG only) (133-144). No readings above
140mg/dl.
Podiatry appt: to be scheduled
Optometry appt: to be scheduled
Immunizations: flu shot needed, refer to health department
O:
Sex: M HT: 68in
BMI: 30
WT: 193 (Previous 197, 202) Race: Caucasian
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BP 148/56 (no HTN medications taken today)
(Prev) 114/76, 112/72mmHg
P: 100
PPBG: 122mg/dl (ate cereal at 8:30AM)
Prev FBG: 8/17 (184, 1hr
PPBG)
Date 7-09
K: 4.3
LFT: WNL
Scr: 0.73
Lipids: WNL, except low HDL 21mg/dl
Date
TC 145 TG 135 LDL 97
HDL 21
EsGFR: (7/09) 148ml/min (CG), 120ml/min (MDRD)
Microalbuminuria: none checked
HbA1C: 5.7% (12.2%) (7/10/09) when hospitalized and diagnosed
Outpt medications: (medication reconciliation documented and verified)
Metformin 500mg PO BID (taking)
Glipizide 5mg PO daily
Clonidine 0.1mg PO TID (not taking)
Lisinopril 20mg PO BID (not taking)
Omeprazole 20mg PO daily (not taking)
OTC
Recommend ASA 81mg PO daily (has not been taking recently)
Herbals
None
A:
DM: Controlled based on SMBG log, hyperglycemia symptom improvement and
A1C today. Reviewed meter instruction technique and importance of checking
BG twice a day before breakfast and 2-hr after meals. Will need comprehensive
annual foot exam and assessment for microalbuminuria, retinopathy
assessment, annual influenza, and low dose ASA. (Goal FBG 70-130mg/dl,
PPBG<180mg/dL, HbA1C< 6%-7% without causing hypoglycemia)
HTN: Uncontrolled based BP today s s in clinic. Patient complained of adverse
events associated with clonidine: sleepiness, lethargy, dizziness. He
discontinued use without tapering as well as stopping lisinopril as he believed
the side effects were related to both agents. Will reinitiate lisinopril at low
dose (10mg) and re-evaluate for titration when RTC in 2 weeks. (Goal < 130/80
DM)
Lipids: Controlled based on recent lipid panel with the exception of his HDL.
Reinforced importance of physical activity as tolerated with his amputation and
contingent on physician approval. Alternatives are swimming, stationary bike as
well as reinforcing principles of the DASH diet and TLC to help improve HDL.
(Goal TC<200mg/dl,TG <150mg/dl, HDL>40mg/dl, LDL<100, optional goal
<70mg/dl)
P:
1. Discussed the importance of checking blood glucose at least BID and
provided log to report values. Provided medication instruction sheet and log for
exercise.
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2. Discussed the s/sx of hypo/hyperglycemia and what to do should they occur.
Confirmed technique for meter instruction and will reassess in 3 months
(December).
3. Reviewed all medications (provided med list) with patient and discussed reinitiation of lisinopril. Continue current dose of metformin 500mg PO BID with
meals, ASA 81mg PO daily, Glipizide 5mg PO daily before breakfast, lisinopril
20mg 1/2T PO daily. Discussed common side effects to watch for with his
regimen.
4. Call with any problems. Encouraged to continue a low-fat, low cholesterol,
moderate CHO diet (130-150grms daily).
5. Expected level of patient adherence is: good.
6. Refer to NP today for comprehensive foot exam and health department for
flu shot.
7. Will notify Dr. X (physician name here) of the pending blood work and
assessment today.
8. Will need f/u lipid assessment in November along with microalbuminuria
assessment, A1C in three months and should be screened for colorectal cancer.
Follow-up standards of care
1. Podiatry q 6 months
2. Dentistry q 6 months
3. Optometry q 6 months
4. Nutrition prn
Signature
Seena Haines, PharmD, BC-ADM, CDE
Pharmacotherapy Specialist
Diabetes Education and Research Center
Time Out: 60 minutes spent counseling/coordinating care
Total Time Spent: 1 HR
By using a standardized format, such as a SOAP note, other practitioners can get an
understanding of the interaction with the patient as well as your assessment and plan to
manage disease states that have been referred. Within the SOAP note example provided,
pay attention to the key elements that pertain to pharmaceutical care such as past medical
history (PMH), review of systems (ROS), and the medication reconciliation. Do all
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medications have an indication for this patient? Screening for duplicate therapy or
omissions is also important. Every medication should be accounted for within the PMH.
Within this SOAP, also note the objective section, which allows you to formulate your
assessment and then plan the two most important sections for communicating the care
given to this patient. The assessment should be as complete as soon as possible so
referring provider can know how the visit(s) has progressed as well as the care. The plan
should be succinct and outline exactly what the goal is for the therapy used. Note the
assessment and plan can be done together in the same paragraph or it can be separated.
No matter which format used, always make sure to account for management issues that
cannot be handled by the pharmacists. Notice that the end of the note contains a plan to
ensure the patient referred to other care providers to handle preventive care that does not
fall into the realm of the pharmacists’ scope. Even though it was not handled directly by
the pharmacist, it is important to show that care is universal and that the pharmacist
understands the entire scope of the patient’s problems.
Basic 7 Lines of Questioning32,33
Location
Quality
Quantity
Timing
Setting
Modifying factors
Associated symptoms
Where is the symptom(s)?
What is it like?
How severe it is?
How long have symptoms been present?
How did it happen or what was the
patient doing?
What makes it better or worse?
What other occurrences have taken place
of importance?
A 21-year-old male (JL) approaches you, the pharmacist, and asks, "What can I take for
my headache?" You ask the patient about his symptoms and he comments about studying
for his final exams all week. “I felt like my head is going to explode this morning.” He
goes on to describe the pain being dull now versus hours earlier. Pain index is 4/10. He
has not taken any over-the-counter medicines, but he did try resting and lying down for
several minutes; it did help some but all the studying and reading made it worse. You ask
JL to describe where the pain is in his head and if it has spread anywhere. JL points to his
head and also neck and shoulder area.
Past medical history is significant for ulcers, and he has no known drug allergies
(NKDA). Current medication: Omeprazole 20mg PO daily and multivitamin PO daily.
The QuEST Method: SCHOLAR-MAC
Symptoms
Characteristics
History
Original pain was head exploding
Dull consistent pain 4/10
Tried resting before presenting today
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Onset
Location
Aggravating factors
Remitting factors
Medications
ALL
Comorbidities
Early this morning
Head and radiates to neck and shoulders
Reading and studying
Resting, lying down
Prilosec
NKDA
PUD