 SOAP

 FARM
 IAO
 S = subjective
Usually given by the patient or caregivers.
May includes:
◦ Complaints (symptoms)
◦ History of presenting illness (recent hx that
pertains to those symptoms)
◦ Past medical history
◦ Medication history (including compliance & ADR)
◦ Allergies
◦ Social & family hx
 O = objective
Data that can be measured objectively.
Includes:
◦ Vital signs
◦ Physical findings (physical examination)
◦ Lab test results
◦ Serum drug concentrations
◦ Various diagnostic test results (ECG, CXR,
biopsy…)
◦ Medication chart (profile) etc.
 A = assessment
Includes:
◦ Medical problems (diagnosis)
◦ DRPs
◦ Clinical progress (eg: “gastritis – resolved”)
 P = plan
Includes:
◦ Add / remove / change drug.
◦ Dosage modification
◦ Monitoring
◦ Communication with pt & health care prof
◦ Counselling, etc.
 F = findings
 A = assessment
 R = resolution
 M = monitoring
 I = care issues
This is similar to A in the SOAP
Includes: DRPs, but it can be “condition-
based” as well. Eg: To review tx of
hypertension.
 A = action (“pharm care action”)
This is similar to P in the SOAP
 O = outcome
To document the outcome of the action
carried out.
 Disease-related
◦ Are all patient’s health complaints being treated?
◦ Is the patient progressing well?
◦ Any drugs contraindicated with the condition?
◦ Any dosage adjustment needed? (renal & liver dz)
◦ Is there possibility that the condition is caused or
worsen by drug use?

Eg: Diabetes
◦ Check signs and symptoms of DM and complication
◦ Vital signs, blood glucose, HbA1c, urea, Srcr etc.
◦ Check hypoglycaemic events
 Medication-related
◦ Special precaution & contraindication?
◦ Proper dosage & regimen?
◦ Proper administration?
◦ Any unwanted side-effects?
◦ Actual and potential interactions?

Eg: Insulin
◦ Proper dosage and regimen?
◦ Review Insulin injection technique.
◦ Proper storage of unused insulin?
◦ Hypoglycaemic events?
◦ Use of other drugs or herbs which may interact with
insulin or lower / raise the blood sugar?
 Patient-related
◦ Knowledge, attitude & perception about the drugs
and conditions.
◦ Compliance
◦ Counselling & education
 Non-pharmacotherapy (diet and exercise)
 JB is a 74-year-old man who comes to the
pharmacy for a refill of his antihypertension
medication, atenolol. As he approaches the
pharmacy counter, he loses his balance
slightly, but he catches himself on the
counter. The pharmacist asks: “Are you OK,
Joe?”. The patient answers: “O yes, I’m fine. I
just stumble a little. I do that quite often
these days. I need a refill of my blood
pressure medicine.”
 RPh: So how long have you been having problems with your
balance?
 Joe: Oh, it’s not a problem. I’ve just been a little light-headed the
past couple of weeks. I guess it’s just old age.
 RPh: How is your energy level?
 Joe: I don’t do a whole lot anymore, so I guess I don’t need much
energy at my age.
 RPh: How have you been feeling otherwise? Have you been
having any other problems?
 Joe: No, otherwise I feel OK.
 RPh: Why don’t you have a seat over here and let me check your
heart rate and blood pressure.
(Joe’s HR is 48 BPM and BP is 114/72 and 112/70 mmHg)
Date & Care issues Action Outcome
time

9/2/10 To review tx of htn Check Patient is

 BP 112/70 compliance / taking atenolol
9 am direction of use 1 tab bd,
 HR 48
(bradycardia) instead of OD
as prescribed
 Light headedness +
 RPh: I notice in your profile that you just started
taking atenolol 2 weeks ago. How have you been
taking it?
 Joe: I take it with breakfast and supper. Just like
my other blood pressure medicine.
 RPh: Actually, you should be taking it just once a
day, and this is probably causing the light-
headedness and decreased energy level. I will go
ahead and get your medicine for you, but make
sure that you take it just once a day.
Date & Care issues Action Outcome
time

9/2/10 Patient has taken Counsel the pt Pt has been

more drug (atenolol) Inform the dr counselled &
9.15 am than necessary dr has been
informed.

12/2/10 Monitor the patient’s Call the patient Pt feels better

condition to ask for his and no more
9 am condition light-headed.
ASSESSMENT CARE PLAN EVALUATION
• Ensure all drug • Address care issues • Record actual patient
therapy is indicated, outcomes
• Achieve therapeutic
effective, safe &
goal. • Evaluate progress
convinient.
• Prevent DRPs • Reassess new problems
• Identify Care
issues

DOCUMENTATION
 Knowledge and skills update
 Communication with patients
 Communication with doctors
 Time management