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LEARNING OBJECTIVES

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  1. Describe the need and benefits of pharmacist documentation of patient encounters in all settings.

  2. Create a problem list from a patient database.

  3. Document a simulated patient encounter using a subjective, objective, assessment, and plan (SOAP) format.

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INTRODUCTION

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Pharmacist documentation of patient encounters is an essential element of providing pharmaceutical care. There are several ways to document patient care activities in the patient medical record. Prior to 1970, free-flowing narrative was the predominant method of documentation. Its primary disadvantage was that it did not provide a mechanism for which multiple providers, who were involved in the care of a single patient, to effectively communicate with each other. The notes were organized differently by each provider and one had to read the entire note to get important information, and yet many times narrative notes would not contain critical information.

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The second approach is the structured approach. In 1968, Lawrence Weed, the director of the family practice residency program at Western Reserve University, became frustrated with the difficulty and variety of ways residents approached the diagnosis and treatment of patients, many of whom had multiple health problems. Initially, he devised a logical, rational, problem-based method of thinking about a patient, which he called SOAP. S stands for Subjective or patient history. O stands for Objective, which includes diagnostic tests and physical examination. A stands for Assessment or diagnosis, and P stands for Plan, which includes treatment, education, and other logistical elements of the care plan. It provided a structure to the diagnostic process. As he implemented this logical approach with his residents, it grew into the problem-oriented medical record (POMR), using the SOAP format to document patient encounters by the patient’s health problems. The advantage of the POMR and SOAP approach is that they improve the quality of patient care through better communication between members of the health care team. In addition, use of the SOAP format guides the provider in a logical stepwise fashion to collect data, evaluate the patient’s problem, and develop a treatment plan. It also allows providers to more effectively follow patients’ progress and evaluate the efficacy of any interventions. In contrast to the narrative style, finding and reviewing patient notes with POMR are very rapid due to the organization of the note. Finally, in addition to improving quality and efficiency it serves a valuable purpose from a medicolegal standpoint. Organized, concise SOAP notes reduce the chances of misinterpretation and have been shown to have a positive impact on malpractice outcomes. Some variations of the POMR and SOAP are the predominant methods of documentation today, even in electronic health records, many of which have a SOAP template that drives writing a visit note. While this chapter teaches the process according to Weed’s original process, the reader should be aware that there are many variations in use today. DAP is data, assessment, and plan. HOAP is history, observation, assessment, and ...

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