Clinical Pearl: Mishaps, Pitfalls, and #Fails Writing a SOAP Note

Written by Authors: Anna Phillips, Pharm.D. Candidate 2022; Mary Douglass Smith, Pharm.D.; and Karen Kibler, Pharm.D. Candidate, Presbyterian College School of Pharmacy
 

Introduction

Learning to write a well-written subjective, objective, assessment, and plan (SOAP) note is often challenging for pharmacy students because of their lack of clinical experience and the different preferences of their professors and preceptors. At the start of professional year 4, many students feel just as unprepared to write a SOAP note as at the beginning of pharmacy school. Mastering the art of writing a SOAP note that is both concise and thorough takes time and practice. With time constraints in classes and different expectations, it can be challenging to feel comfortable in your work when submitting a SOAP note. Some of the challenges students face include whether to combine the assessment and plan, how to cite the rationale and guidelines, and how to make an appropriate assessment and plan for patients with complex conditions. At Presbyterian College School of Pharmacy, SOAP notes are introduced in professional year 1, before the student has clinical reasoning skills or much therapeutic knowledge. Classes and labs provide some opportunities to write a SOAP note, but it is often fragmented into individual parts or completed with a group. In addition, non-simulated ambulatory care rotation experiences are rare for introductory pharmacy practice experiences. Partly because of these factors, many students make the same SOAP note-writing mistakes. This article identifies where these pitfalls are most likely to occur and gives tips for successful SOAP note writing.

 

SOAP Note Components

Subjective:

1. Common mistakes:

a. Students list the chief concern in their own words instead of the patient’s.

b. Students list objectively obtained signs and symptoms instead of listing symptoms reported by the patient.

2. Helpful tips:

a. It is okay to give the patient’s comments word-for-word from the chart into your SOAP note.

b. To keep subjective and objective information separate, create a list of things that are always subjective and always objective.

Objective:

1. Common mistakes:

1. Normal vital signs are not included.
   1. Always address vital signs, whether normal or abnormal.
2. Pending laboratory tests or cultures are not included.
   1. These should be included if they are clinically relevant.
3. Only abnormal laboratory values are included.
   1. Normal laboratory data can help rule out differential diagnoses and should be included.

2. Helpful tips:

a. Create a SOAP note framework that you can duplicate for all of your SOAP notes.

i. Include a table for laboratory values, and bold or highlight abnormal values.

 

	PT	PTT	INR	K+	Glucose	SCr	CO2	BUN
2/3/21	11.5 seconds	34 seconds	2.5	3.0 mEq/L Low	130 mg/dL High	2 mg/dL High	19 mEq/L Low	26 mg/dL High

b. Create a chart that can be included on every SOAP note showing pending laboratory tests, completed laboratory tests and their results, future planned laboratory tests, and the applicable units for each.

Assessment:

1. Common mistakes:

a. Not identifying the patient’s chief concern as the primary problem

b. Not including every patient problem

c. Problems not prioritized in order of severity

d. Appropriate/up-to-date guidelines not cited for assessment rationale

e. Leaving off medications that do not appear to have an indication

f. Beginning to write the plan in the assessment section

i. Statements such as “Medical treatment is warranted” or “Medication should be changed” should be part of the plan, not the assessment.

g. Leaving off goals of therapy for each problem

2. Helpful tips:

a. List all problems in order of severity.

i. Remember: If patients are in an acute setting, their primary problem is what is going to kill them first. If they are ambulatory, their primary problem is the reason they came in unless something else is causing them significantly more harm.

b. All of the patient’s problems should be included, even if controlled.

c. Create a document folder with up-to-date treatment guidelines so that you can quickly assess and cite guidelines in your SOAP notes.

d. To save time and prevent retyping, start a document with the common disease state goals/assessment statements saved.

i. Example: According to the 2019 ACC/AHA guidelines, a patient with atrial fibrillation should have a goal heart rate at rest of less than 80 beats/minute, and less than 100 beats/minute during exercise. Other goals include achieving normal heart rhythm (sinus rhythm), preventing blood clots, and reducing the risk of stroke. Today, the patient’s heart rate was ___ beats/minute, which is/is not at goal. The patient’s CHADS₂-VASC score of __ places this patient at an increased/decreased risk of cardiovascular events such as stroke.

e. Keep patient-centric goals in mind. If a guideline-specific goal is too strict for a certain patient population (i.e., older adults), make sure this is noted. It is also important to be able to back up these goals with clinically proven evidence.

f. Consider why the health care team is treating a problem when writing out goals. The goals may include objective measures (e.g., blood glucose greater than 100 mg/dL; pain level greater than 4/10) or subjective measures that can be more patient-specific (e.g., decreasing the risk of diabetic complications such as retinopathy, neuropathy, and nephropathy; achieving less sedation and daytime drowsiness from pain medication). These can also be included on a document to copy and paste, when needed.

g. Do not “diagnose” a patient with a condition because of a medication without an indication. For example, for patients taking modafinil who do not have narcolepsy on their problem list, don’t categorize this problem as narcolepsy. Instead, categorize this in your assessment as “drug without indication.”

i. Remember: Medication without an indication is a problem that should be addressed. Always look at a complete medication list to ensure patients are being treated adequately.

h. Compare the assessment and plan once the SOAP note is completely written. If you repeat treatments in the plan that were already addressed in the assessment, it does not belong in the assessment.

Plan:

1. Common mistakes:

a. Omitting or incorrectly citing guidelines

b. Not stating the risks or benefits of the current plan as the rationale for treatment modifications

c. Including a vague monitoring plan

d. Forgetting to create a plan for controlled disease states

e. Introducing new information in the plan. All assessments of clinical severity or control should be included in the assessment, not the plan.

2. Helpful tips:

a. Remember: The more detailed and specific, the better.

b. Always have a rationale for every medication modification!

c. The rationale behind the plan should always be supported by guidelines or other reliable sources.

i. If you are giving recommendations according to a study and not guidelines, reference both and explain why the study is more appropriate for the patient than the guidelines.

ii. When adding the rationale, include the benefit or risk of adding, modifying, continuing, or discontinuing a medication, as well as the supportive evidence-based guidelines or primary literature.

d. Always include a detailed monitoring plan, including what to monitor and when it should be monitored.

i. Good: Check the LFTs and lipid panel at baseline (today). Monitor the LFTs 4–12 weeks after initiation and while titrating to goal. Monitor the lipid panel annually. The treatment goal should be to reduce the LDL by 50% from baseline. Counsel the patient on symptoms of myopathy, including muscle pain or weakness and cola-colored urine. Discontinue rosuvastatin if AST/ALT becomes 3 × the ULN.

ii. Not specific enough: Monitor the patient’s LFTs and lipids. Counsel the patient on signs and symptoms of myopathy.

e. Controlled disease states should be stated in the plan. It is appropriate to address when/what to monitor as well as what medication should be continued.

i. Remember: Controlled disease states are only controlled right now. If these disease states become uncontrolled, it’s better to have a plan laid out for how to address this than to have to create something from scratch.

f. Like the assessment, compare your plan and assessment after you have finished your SOAP note. If anything that informs treatment decisions (like control of a disease state or pertinent laboratory values) is in both sections, move it to the assessment section.

i. Remember: No new information should be introduced in the plan. If you are having to include values or information in your plan that influences your treatment decisions, that should be part of the assessment.

Final Tip:

The best way to improve your SOAP note writing is to get as much feedback as possible. Write as many as you can and always ask for feedback from your professor or preceptor. It can be frustrating at first, but with practice and avoidance of these common mistakes, you will be on your way to efficiently writing SOAP notes!

 

 

SOAP Note Writing Key Points

1. Address every patient problem.

2. Appropriately rank problems in order of severity, with the patient-reported problem as the primary problem (unless there is one that would kill/harm them faster).

3. Appropriately cite up-to-date guidelines and trials (if needed) in your assessment.

4. Always address medications that do not appear to have an indication.

5. The best SOAP notes are specific and detailed regarding why medication changes need to be made, what to monitor, and patient-specific goals.

6. Always ask for feedback!

 

Helpful Resources

1. Haines SL, Brown TR. Communication & documentation for an ambulatory practice. Available at https://www.ashp.org/-/media/store-files/p2449-sample-chapter-6.

2. Cipolle RJ, Strand LM, Morley PC. Chapter 6: The assessment. In: Cipolle RJ, Strand LM, Morley PC, eds. Pharmaceutical Care Practice: The Patient-Centered Approach to Medication Management Services, 3rd ed. McGraw-Hill, 2021. Available at https://accesspharmacy.mhmedical.com/content.aspx?bookid=491&sectionid=39674906.