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S:

What does the patient tell you?

  • “Opening one liner”

  • Patient-reported information not documented by objective sources (PMH, FH, SH)

    • Include anything that the patient states or denies regarding symptoms

  • Patient-reported OTC med/herbal medication list (include strength, frequency, and duration if known)

O:

What information do you get from the records?

  • Pharmacy record’s medication list (include strength, frequency, quantity, and fill dates in the pharmacy)

    • eg, Hydrochlorothiazide 25mg PO QAM; #30 tablets, filled 07/29/18

  • Med allergies (if from pt—should be in the subjective)

  • Relevant vital signs, lab values, diagnostic tests (including date) (if the pt tells you these values—should be in subjective)

A:

Think about the subjective and objective information provided. What is your judgment about the management of each disease state?

  • For each disease state, consider indication, effectiveness, safety (D-D interactions, dosing adjustments, contraindications, duplication of tx, etc.), and adherence

  • Reference guidelines, mention goals/reference ranges

    Problem 1: [insert primary problem]

    Assessment

    • Controlled/not controlled, at goal/not at goal, tolerating/not tolerating therapy, no change is indicated/patient may benefit from incr/decr in dose, D-D interaction, duplication of therapy, etc.

    Problem 2: [insert additional problem]

    Assessment

    • Controlled/not controlled, at goal/not at goal, tolerating/not tolerating therapy, no change is indicated/patient may benefit from incr/decr in dose, D-D interaction, duplication of therapy, etc.

P:

Plan: What is your action plan for your patient?

  • Should include action verbs

  • Need to include specific medication, dose, and frequency, nonpharmacologic tx, AND monitoring

    Problem 1: [insert primary problem]

    • Treatment: Continue tx, d/c treatment, change dose/frequency

    • Monitoring: what, when, how

    Problem 2: [insert additional problem]

    • Treatment: Continue tx, d/c treatment, change dose/frequency

    • Monitoring: what, when, how

    Follow-up: When should the patient come back for a follow-up appointment?

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