This document outlines how to present a case using the SOAP format. It includes sections for Subjective evidence (S) such as patient demographics, chief complaints, medical history, physical exam findings and provisional diagnosis. Objective evidence (O) such as lab results and investigations. Assessment (A) which is the final diagnosis. And Plan (P) which contains the proposed treatment plan, goals, medications, monitoring for interactions or errors, and pharmacist interventions.

1. How to make a Case Presentation in SOAP Format
By: Dr. Ankit Gaur (B.Pharm, M.Sc, Pharm.D, RPh)

2. Introduction:
 About the disease (Definition).
 Its classification or types.

3. Subjective Evidence (S):
Patients Demographics/Detials:
 Name: XYZ
 UHID no: 1234556342
 Gender: Male or female
 Age: in yrs
 DOA: DD/MM/YYYY
 Unit/Ward in which patient is admitted
Chief complaints (C/O) of the patient at the time of
admission.
 Other sign and symptoms.
Past Medical History:
 Any medically relevant history including co-morbide conditions.
 Any Drug allergies.

4. Past Medication History:
Drugs which are used in past prior to admission or a
few weeks ago.
Social History:
Addiction to any drug or substance such as alcohol,
smoking.
Diet: Veg or non-veg
In some cases social activity
Family History:
Related to genetic disorders or condition similar to the
patients present illness.

5. Physical Examination/Findings:
 Vitals signs such as Respiratory Rate (RR), Heart
Rate/Pulse Rate (HR/PR), Temperature, Blood Pressure
(B.P).
 Cardiovascular sounds such as murmurs.
 Respiratory system such as rales/crackles, Bilateral air entry
e.t.c
 CNS Orientation in terms of Time, Place, Person (T.P.P),
and whether patient is calm, cooperative or not.
 PICCLE ( Pallor, Icterus, Cyanosis, Clubbing,
Lyphadenopathy/Lymph node enlargement,
Edema/Swelling) Present or not.
Provisional Diagnosis.

6. Objective Evidence (O):
 It includes all types of Biochemical investigations such
as LFT, RFT, CBC.
 It also includes all types of other Radiological or Lab
investigations.
Assessment (A):
Based on subjective and objective evidence Final
Diagnosis which is made is known as the Assessment.

7. Plan (P):
 It includes the therapeutic plan proposed to treat the
patients current medical condition.
 It includes both pharmacological and non
pharmacological treatments.
 It also includes Goals or Objectives which are to be
achieved with the help of treament.
Brand name Generic name Dose Rou
te
Fre
q
D
-1
D
2
D-
3
D
-4
D
-5
D
-6
D
-7
Inj. Tazar () Piperacillin
(4gm)
Tazobactum(0.
5gm)
4.5g
m
IV TDS / ̸ ̸ ̸ / / /

8.  Comparison of the plan with the standard treatment
guidelines.
• Drug interactions ( Drug-Drug, Drug-Lab, Drug-Food,
Drug-Alcohol Interactions).
• Dose adjustment (Renal or Hepatic Impairment,
Geriatric or Pediatric Patient).
• High risk medications monitoring.
• Medication errors ( Prescribing, Transcribing,
Dispensing, Administration Errors).
• Unjustified Anti-microbial use ( Stewardship).
• Surgical Prophylaxis.
Pharmacists Intervention: