SOAP note

2020 Applied Pharmaceutical Care I SOAP Rubric

Subjective Proficient (3 points)

Needs Improvement (2 points)

Significant Deficiency (1 point)

□ CC □ HPI □ PMHx □ FH □ SH □ ROS

□ All relevant items complete and pertinent to support their A/P, in their own words □ Complete sentences, tells a story

□ Most relevant items complete and pertinent in their own words

□ Missing one or more item(s) necessary to support the A/P □ Information cut/pasted from case (Plagiarism) □ Falsifying data

Objective Proficient (3 points)

Needs Improvement (2 points)

Significant Deficiency (1 point)

□ Medications - generic (Brand) - dose - route - frequency □ Allergies/Adverse Events - Offending agent AND Reaction □ Pertinent labs / diagnostic tests □ Vital signs □ Rating scales (ex pain, psychiatric etc.)

□ All relevant items complete and pertinent to support their A/P

□ Most relevant items complete □ Most items pertinent □ Some items included that are not pertinent

□ Missing two or more item(s) necessary to support the A/P □ Falsifying data

Assessment & Treatment Goals

Proficient (3 points)

Needs Improvement (2 points)

Significant Deficiency (1 point)

□ Problems listed -New / Previously identified medical problems -Drug-related problems included and identified by disease state not DRP language □ Problems have treatment goals -Medication -Non-drug therapy/lifestyle -Etc. □ Problems are accurately assessed - Controlled/Uncontrolled - Adherent/Non-adherent - Justification for therapy decision □ Primary or most urgent problem correctly identified as such □ Secondary or less urgent problems are prioritized in a patient-specific manner □ Evidence-based (supported by primary literature and/or current guidelines)

□ All problems listed, accurately assessed, and appropriately prioritized □ All problems have complete treatment goals □ All assessments supported by evidence based medicine

□ Most problems listed □ Most problems accurately assessed □ All problems appropriately prioritized □ Most problems have treatment goals □ Most recommendations are evidenced based when available

□ Primarily problem not appropriately prioritized or not addressed □ No recommendations are evidenced based when available □ Significant error made in assessment that could potentially cause patient harm □ DRP language used that is not collaborative

Plan Proficient (3 points)

Needs Improvement (2 points)

Significant Deficiency (1 point)

*You will need to address lifestyle recommendations for every patient problem, as applicable

□ Problem listed in assessment matches the planned actions in this section □ Medications/OTC Recommendations - generic (Brand) - Appropriate dose, route, frequency, duration, administration - If IV: dilution/ infusion rates □ *Non-medication Recommendations - Lifestyle recommendations - Procedures - Quality of life impact - Medical, social, cultural, and ethical recommendations (as applicable) □ Patient Counseling - Key patient counseling/education (administration, warnings, most common and/or severe side effects) on new or adjusted medications as applicable to setting (inpatient vs. ambulatory care) -Adherence recommendations □ Monitoring - Drug monitoring (for each drug) - Disease state monitoring (for each disease state) - Includes specific labs to monitor and frequency of monitoring □ Follow-up - Patient follow-up appointments for each problem/disease state as applicable to setting (inpatient vs ambulatory care)

□ All problems match those listed in the assessment section □ All medication/OTC recommendations are complete □ All non-medication recommendations are complete as appropriate □ All patient counseling points included for new or adjusted medications □ All monitoring parameters included for each drug and disease state and include lab orders, values to be monitored and frequency of monitoring □ Follow-up is included for all problems/disease states □ All recommendations are safe, effective and routinely accepted in practice

□ Most problems match those listed in the assessment section □ Most medication/OTC recommendations are complete □ Most non-medication recommendations are complete as appropriate □ Most patient counseling points included for new or adjusted medications □ Most monitoring parameters included for each drug and disease state and include lab orders, values to be monitored and frequency of monitoring □ Follow-up is included for most problems/disease states □ Most recommendations are safe, effective and routinely accepted in practice

□ A recommendation is made which is a “fatal flaw” or would cause significant harm to a patient

□ Recommendations are safe, effective and routinely accepted in practice

Construction / Organization Proficient (3 points)

Needs Improvement (2 points)

Significant Deficiency (1 point)

□ Note construction - Organized, effective, clear and concise - Appropriate grammar and free of spelling errors - Note is written without reference to pronouns - Does not use: “I”, “we”, “you”, etc. □ Medical abbreviations/ terminology/ language is professional, appropriate, and courteous.

- AVOID use of “SHOULD” □ References - Appropriate references utilized - Appropriate citation format

□ Construction of SOAP note is organized, effective, clear and concise. □ All medical abbreviations/terminology/ language used correctly, professional and courteous* □ All information in appropriate sections □ Little to no (0-1) misspellings and/ or grammatical errors □ NO use of unapproved medical abbreviations □ Included references are appropriately cited (i.e. guidelines, studies)

□ Construction of SOAP note is disorganized, no clear direction or structure, not concise. □ Most medical abbreviations/ terminology/ language used correctly and professionally □ SOAP note uses inappropriately judgmental language or vague terminology □ Some information NOT in appropriate sections □ few (2-3) misspellings and/or inappropriate abbreviation or terminology □ References are included but are not cited properly

□ Unprofessional tone/ language that would be considered inflammatory or derogatory □ Many instances (>4) of misspellings, inappropriate abbreviations or terminology □ No references listed or suboptimal references used.

*Examples: “Recommend that the patient discontinue metformin therapy” NOT “Someone needs to discontinue the metformin”