Pharm Notes

[Montray Yadav]

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Objective. Clinical documentation is an important element of patient care that pharmacy students traditionally learn through subjective-objective-assessment-plan (SOAP) notes. In clinical practice, pharmacists often document more succinctly, both in length and time, using formats such as consult notes. The objective of this study was to assess consult note assignments for third-year pharmacy (P3) students.Methods. Consult note assignments were implemented in a P3 skills laboratory course by converting SOAP notes to consult notes. The series began with an introduction and a practice consult note. Four graded notes were then completed throughout the semester, whereby the time allotted for writing decreased throughout the semester. To assess the series, grades and estimated time to completion were collected for each graded note. A survey given before and after the course assessed student self-confidence in overall documentation, specific elements of consult notes, and concerns related to writing. Friedman tests were used to compare grades and times. Wilcoxon signed rank tests were used to compare self-assessments.Results. The median grades on the four consult notes were 92%, 88%, 80%, and 90%. Median times for completing each note were 75 minutes, 120 minutes, 60 minutes, and 60 minutes. Students' self-confidence in writing consult notes significantly increased, as did five of the six individual elements.Conclusion. The consult note assignments allowed students to practice documenting patient care in a succinct format with consideration for time efficiency. Further work should evaluate best pedagogies for teaching documentation skills and assess the impact on performance during advanced pharmacy practice experiences.

These notes serve as a primary source to stay informed about essential dates, impending deadlines, upcoming exam schedules, and additional pertinent details. By regularly referring to your class notes, you can effectively organize your academic responsibilities, prepare adequately for exams, and ensure you never miss any important events or submissions.

After disasters such as hurricanes, access to prescription drugs might be limited or inaccessible. For example, after Hurricane Ivan made landfall near Mobile, Alabama, in 2004, an assessment of its impact on pharmacies in the affected areas found that 53% had depleted supplies and at least 26% had to prioritize distribution to patients because of limited supplies (1). A 2005 study of Hurricane Katrina evacuees in San Antonio, Texas, found that disaster medical assistance teams were more prepared to provide for acute than chronic illnesses although more than two thirds (68%) of patients requested drugs to treat chronic conditions (2). Understanding the prescribing practices of a region can inform post-disaster medication needs and planning for future emergencies.

On September 20, 2017, Hurricane Maria made landfall in Puerto Rico as a Category 4 hurricane. Five days later, only approximately 29% of pharmacies reporting to Healthcare Ready, an organization that provides information on access to pharmacies during an emergency, were open (3). CDC summarized data within the IQVIA data source (formerly IMSHealth, QuintilesIMS)* to supply the U.S. Department of Health and Human Services emergency response team with projections of formulary health care needs following Hurricane Maria. Prescription data can also highlight important chronic disease concerns for a community.

The distribution of pharmaceutical dispensing practices identified using the IQVIA database can provide information for planning both before and after a disaster. The most frequently prescribed drugs help focus immediate supply measures for response and recovery efforts, supporting a vital public health need. The IQVIA database used in this analysis is limited to retail facilities and does not include hospitals or other institutions such as nursing homes. Furthermore, some critical drugs might not be represented in this data set, including insulin, which can also be purchased over the counter; hence, some of the prescribed quantities in this data set could be an underestimate of medication needs. Although insulin was not a most frequently purchased or prescribed drug, it is a daily need for persons with insulin-dependent diabetes and should be prioritized. To have a more complete picture of important drugs that might be needed after a disaster, multiple data sources, including drug sales data to hospitals, clinics, and nursing homes, as well as information provided by third-party claims adjudication data, could be analyzed to inform public health activities and guide collaborations with drug suppliers to respond to and recover from large-scale disasters.

1Epidemic Intelligence Service, CDC; 2Geospatial Research Analysis and Services Program, Office of Environmental Health Emergency Management, National Center for Environmental Health/Agency for Toxic Substances and Disease Registry, CDC; 3Office of the Director, National Center for Immunization and Respiratory Diseases, CDC; 4Division of Emergency and Environmental Health Services, National Center for Environmental Health, CDC; 5Division of Strategic National Stockpile, Office of Public Health Preparedness and Response, CDC; 6Division of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC; 7IQVIA Government Solutions, Durham, North Carolina; 8Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, CDC.

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The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way.[1][2][3]

This widely adopted structural SOAP note was theorized by Larry Weed almost 50 years ago. It reminds clinicians of specific tasks while providing a framework for evaluating information. It also provides a cognitive framework for clinical reasoning. The SOAP note helps guide healthcare workers use their clinical reasoning to assess, diagnose, and treat a patient based on the information provided by them. SOAP notes are an essential piece of information about the health status of the patient as well as a communication document between health professionals. The structure of documentation is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record.[4][5][6]

The CC or presenting problem is reported by the patient. This can be a symptom, condition, previous diagnosis or another short statement that describes why the patient is presenting today. The CC is similar to the title of a paper, allowing the reader to get a sense of what the rest of the document will entail.

Current medications and allergies may be listed under the Subjective or Objective sections. However, it is important that with any medication documented, to include the medication name, dose, route, and how often.

This is a list of the different possible diagnosis, from most to least likely, and the thought process behind this list. This is where the decision-making process is explained in depth. Included should be the possibility of other diagnoses that may harm the patient, but are less likely.

This section details the need for additional testing and consultation with other clinicians to address the patient's illnesses. It also addresses any additional steps being taken to treat the patient. This section helps future physicians understand what needs to be done next. For each problem:

The order in which a medical note is written has been a topic of discussion. While a SOAP note follows the order Subjective, Objective, Assessment, and Plan, it is possible, and often beneficial, to rearrange the order. For instance, rearranging the order to form APSO (Assessment, Plan, Subjective, Objective) provides the information most relevant to ongoing care at the beginning of the note, where it can be found quickly, shortening the time required for the clinician to find a colleague's assessment and plan. One study found that the APSO order was better than the typical SOAP note order in terms of speed, task success (accuracy), and usability for physician users acquiring information needed for a typical chronic disease visit in primary care. Re-ordering into the APSO note is only an effort to streamline communication, not eliminate the vital relationship of S to O to A to P.

A weakness of the SOAP note is the inability to document changes over time. In many clinical situations, evidence changes over time, requiring providers to reconsider diagnoses and treatments. An important gap in the SOAP model is that it does not explicitly integrate time into its cognitive framework. Extensions to the SOAP model to include this gap are acronyms such as SOAPE, with the letter E as an explicit reminder to assess how well the plan has worked.[7][8][9][10]

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