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Introduction

The purpose of this activity is to allow students to practice their skills in using the Pharmacist Patient Care Process to collect, assess, and plan on a patient from the community pharmacy setting. Students will then create a community pharmacy-based SOAP note to document the encounter.

Learning Objectives
  1. Demonstrate the ability to obtain a complete medical, medication, and social history from a patient.

  2. Interview patients using open-ended questions and select appropriate follow-up questions.

  3. Construct problem lists based on health and medication information collected.

  4. Integrate all previously learned disease states and pharmacotherapy to identify and assess medical-related, patient-related, and medication-related problems.

  5. Evaluate the appropriateness of medications considering indication, effectiveness, safety, and adherence.

  6. Assign problem severity and prioritize medical and medication problems.

  7. Create an individualized, patient-centered, evidence-based care plan with measurable goals for each medical or medication-related problem, taking into consideration health-related and patient-related needs.

  8. Create an education plan for the patient that includes education about disease management, maintenance, and/or preventive medicine.

  9. Determine appropriate follow-up and monitoring for each medical or medication-related problem.

  10. Make appropriate referrals to other HCPs or medical services.

Foundational Knowledge Required

Patient interviewing skills, patient assessment, knowledge of electronic health and pharmacy records, writing SOAP notes, Pharmacists’ Patient Care Process, pharmacotherapy and disease state guidelines related to assigned disease states, use of drug information resources

Suggested Resources
  • Herrier RN, Apgar DA, Boyce RW, Foster SL. Patient Assessment in Pharmacy. McGraw-Hill Professional; 2014.

  • Ellis AW, Sherman JJ. Documentation and counseling and motivational interviewing. In: Community and Clinical Pharmacy Services: A Step-by Step Approach. McGraw-Hill Education; 2013.

  • Dipiro, et al. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. McGraw-Hill; 2017.

  • David JA, Esherick JS. Current Practice Guidelines in Primary Care 2019. McGraw-Hill Education; 2019.

  • Malone PM, Malone MJ, Park SK. Drug Information: A Guide for Pharmacists. 6th ed. McGraw-Hill Education; 2018.

Assignment Instructions

Review the Patient Dialogue Script and utilize vitals and labs provided below to complete the IPPE Collect, Assess, and Plan Worksheets. Once the worksheets are completed, use the information to create a written note using the SOAP Note Template. The note will be graded using the Rubric.

Vitals

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Height Weight BMI
66 in 220 lbs 35.58 kg/m2

Labs

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Lab Value Normal Range Information Source Concerns/Comments
Sodium 136 mEq/L 133–146 mEq/L Chart Labs from 2 weeks ago
Potassium 4.4 mEq/L 3.5–5.4 mEq/L Chart  
Chloride 97 mEq/L 95–107 mEq/L Chart  
HCO3 25 mEq/L 24–30 mEq/L Chart  
BUN 13 mg/dl 6–20 mg/dl Chart  
SCr 0.7 mg/dl 0.60–1.30 mg/dl Chart  
Blood Glucose 93 mg/dl 70–99 mg/dl Chart  
A1c 7.8% <5.7% Chart  

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