This document outlines the components and importance of patient medical documentation. It discusses medical records, SOAP notes, and the subjective, objective, assessment, and plan sections. Key information includes: 1. Medical records and SOAP notes are forms of patient documentation that help facilitate communication between healthcare providers and allow for education and research. 2. The subjective section includes a patient's history and social information. The objective section includes physical exams, diagnostic tests, lab values, and vital signs. 3. The assessment involves the clinical diagnosis with the physician and pharmacist. The plan outlines the treatment, education, monitoring, and follow-up to achieve defined health outcomes.

1. Patient medical documentation
Made by:
1. Abdurahman Salah Ali
apood7932869@gmail.com

2. Medical record[1]
Medical record is a form of documentation for the patient made by health care
staff usually nurses and clinical pharmacists written in a clear language and
standard format and should include:
1. Patient history
2. Consultations to other health care team
3. Drug orders
4. Drug adjustments (dose, dosage form, time, frequency)
5. Drug-related problems
6. Monitoring
7. Resolution plan

3. Importance:
1. A better way for communication among the medical staff.
2. A better way for communication between healthcare organizations.
3. Help in education and research.
4. Avoid the most of human mistakes in prescribing.
5. Can help decrease time waste specially if automated.
6. Formal and organized.

4. SOAP notes[1]
SOAP notes is a type of patient medical record documentation in which S stands
for subjective O stands for objective A for assessment and P for plan.[2]
A. Subjective: (non measurable)descriptive information of the problem or the
reason of the encounter reported by the patient including history of past
medication etiology of the disease, past illness, and social life cannot be
confirmed by procedures or diagnostic tests.

5. B. Objective: (measurable) done by the medical team and includes intervention
of physicians and medical equipment summarized by values and numbers by
which a proper diagnosis can be established.
C. Assessment: is the summation of subjective and objective data includes
conclusion and differential diagnosis and the reason for this diagnosis.
D. plan: the final step which includes drugs (maintained or changed), patient
follow up, monitoring, and counselling

6. A. Subjective[3]
Includes:
1. History of the past illness
2. History of present illness
3. History of drugs: taken and stopped
4. Social history: alcohol, tobacco, economic status, and occupation
5. Diet
6. Review of systems
7. Drug and food allergies
8. Chief complaint

7. where to collect these information:
1. Patient himself
2. Caregiver
3. Family
4. Past PMR (if found)
5. The community pharmacy that the patient deals with
6. Prescriptions
7. patient’s own medicines
8. Other health organizations (private hospitals, clinics,…)

8. B. Objective[3]
Includes:
1. Physical examination: in which the physician tries to find any sign of the
potential disease or any other illness.
(palpation, percussion, auscultation, inspection, and neurological
examination)[4]
2. Diagnostic tests: like x-ray, CT scan, MRI, ECG, endoscopy and usually
describes what can’t be seen with the naked eyes.

9. 3. Lab values:[5]
• valuable tools that may be used to gain additional information about the
patient.(not therapeutic) they can be used to differentiate among possible
diagnoses, confirm a diagnosis, assess current status, or evaluate response to
therapy when history and physical exam alone cannot. Selection of
laboratory tests is based on clinical judgment, with evidence-based medicine
used to guide these decisions.
• Reproducible
• measurable
• In all laboratory tests a specimen is taken from the patient.
examples: renal function tests (creatinine, alb), liver function tests (AST, ALT),
lipid profile (LDL, HDL, TG)

10. 4. Serum drug concentration:[1]
Aid in confirming actual and potential adverse drug reactions, toxic dose, and
drug efficacy.
5. Vital signs:[1]
Blood pressure (BP), pulse(P), temp(T), respiratory rate(RR)

11. C. Assessment[6]
In which the clinical pharmacist cooperate with the physician to achieve the
best treatment.
• Diagnosis or differential diagnosis
• Identification of Dose regimens problems
• Identification of drug-drug interactions
• Identification of drug-food interaction

12. • Drug safety and efficacy
• Additional drugs requirements
• Patient compliance
• Identification of drug-disease interactions
• May order other diagnostic or laboratory tests to confirm a diagnosis

13. D. Plan
It should be:
1. Achievable 2. Each drug should be compatible with each other
3. the least side effects
4. Safe and economic drugs 5. achieve definite outcomes
6. compatible with the compliance of the patient( the least number of doses)
Includes:
• Treatment plan
• Patient education
• Follow up
• Monitoring

14. Monitoring[6]:
Many drugs, due to its low therapeutic index, needs TDM which in a fairly lower
dose can be ineffective or toxic in case of increasing the dose like
antiarrhythmic drugs (lignocaine), cytotoxic drugs(methotrexate), or
anticonvulsants.
Steps:
1. Collection of patient data
2. Statement of therapeutic goals
3. Selection of medication
4. Establishing of monitoring parameters
5. Identification of resolution problems

15. Patient education[6]:
Help the patient to be fully understanding of his illness and most compliant to
medication therapy and it’s about:
1. Actual and potential adverse drug reactions.
2. Time, frequency, and route of the dose
3. Etiology and prognosis of his disease
4. How to administer a drug device

16. Follow up[6]:
- Aids in achievement of best compliance of the patient and best outcomes and
resolution.
- Determine actual outcomes of therapy for the patient and comparing it with
suspected outcomes in which:
1. determine efficacy and safety of the therapy
2. evaluate adherence
3. establish the current status of the patient’s medical condition
4. help increase learningand knowledge of the practitioner

17. References
1. McCarthy, Michelle w. (n.d.). clinical pharmacy skills. In oxford American handbook of clinical
pharmacy (pp. 34–53). Newyork, Newyork: oxford university press Inc.
2. Timothy, J. I., Bruce, R. C. D., & Peggy, C. Y. (n.d.). Documentation of Pharmacist Interventions.
In Instructor's Guide to accompany Pharmacotherapy Casebook (5th ed., pp. 99–104).
3. College of Pharmacy Standardized SOAP note, Rubric, &expected components. (2017,
November). Oregon State University.
4. chemocare.com/chemotherapy/before-and-after/the-physical-examination-and-health-
assessment.aspx
5. Warburton, J., & Beale, L. (n.d.). General/laboratory data. In clinical pharmacy and
therapeutics (6th ed., pp. 81–102). Elsevier.
6. Suzan, M. S. (n.d.). Clinical Drug Monitoring. In Boh’s Pharmacy Practice Manual: A Guide to the
Clinical Experience (4th ed.). Philadelphia: Lippincott Williams & Wilkins.