MANILA CENTRAL UNIVERSITY

College of Pharmacy

Documentation of Pharmacotherapy SUBJECTIVE:

Interventions
• Chief complaint, History of present
Introduction: illness; why the patient is being seen

If there is no documentation, then it didn’t happen! This OBJECTIVE:

viewpoint is applicable in all heath care settings.
Physicians, nurses, respiratory therapist, social workers and
• Evaluation of the patient, which may
other health care providers generate and maintain detailed
notes regarding the patient’s situation and their efforts to include appearance, mood, affect,
achieve the best possible outcomes for the patient. mental status.
Documentation in health care Setting ASSESSMENT:
• It chronologically outlines the care the • Analysis or conclusion about the
patient received. patient’s current status, behavior,
• It records pertinent facts, findings, and evidence of progress, response to
observations about a patient’s health intervention or medication, and change
history, including past and present in functional status;
illnesses, examinations, tests,
treatments and outcomes. PLAN:
• It serves as a form of communication
• Interventions or actions taken in
among health care practitioners, an
response to assessment, collaboration
important element that contributes to
with others, plan for the next session,
the quality of care provided.
change in diagnosis and documentation
that the patient was informed of
changes in interventions or
Principles of Documentation medications.
1. Facilitates the ability of providers to
evaluate and plan the patient’s
immediate treatment and monitor
his/her health over time.
2. Facilitates communication and
continuity of care among providers
involved in the patient’s care.
3. Facilitates appropriate utilization
review and quality of care evaluations.
4. Facilitates collection of data that may
be useful for research and education.

SOAP FORMAT

CLINICAL PHARMACY LECTUREï DOCUMENTING OF INTERVENTIONS 1

PREPARED BY: ELVIRA V. DE LEON, RPH, MSPH