Written Communication SOAP Notes.pptVIP

Written Communication SOAP Notes Presented by: Marlo Murray, 2010 PharmD candidate PHARM 504 2/12/2010 Objectives Discuss the importance of written communication in the healthcare setting Identify the benefits of using a standard format for written communications Define the parts of a SOAP note Provide tips on how to write a good SOAP note Introduction Written Communication Useful tool to pass along information when transitioning patient care from one person to another: Shift changes From one healthcare field to another Guidance for future encounters Other reasons to write things down What should you include in your written note? NEVER include patient identifiable information: A 78 year old African American female with Type II diabetes is being discharged today after being admitted for heart failure exacerbation. She was admitted several days ago, and has been treated with insulin while in-house. The medical team is now deciding which diabetes medications to restart upon her discharge. The drugs she was on before she came here were: Metformin 850mg PO TID, pioglitazone 45mg PO daily, Losartan 50mg PO daily, Furosemide 40mg PO daily, carvedilol 25mg PO BID, simvastatin 20mg PO qhs, aspirin 81mg PO daily, and Tylenol Arthritis 650mg caps PRN joint pain. She has had diabetes for 6 years, as well as hypertension for about 30 years, and high cholesterol for about 10 years. She has also had osteoarthritis for 20 years. There is a history of diabetes in her mom and siblings, and her dad died of an myocardial infarction at age 42. She doesn’t smoke, drink or use illicit drugs. She lives alone but spends time with friends and family several times a week. Her diet before she was admitted included drinks sweetened with Splenda, about 4 carbs per meal, and low sodium intake. She takes daily walks and does tai-chi classes. Her serum creatinine is 1.2 and her weight it 64 kilograms. She also is noted to have edema, cough, jugular venous distention which has r