level: Documentation Formats
Questions and Answers List
level questions: Documentation Formats
| Question | Answer |
|---|---|
| SOAP Format May include: > complaints (symptoms) > History of presenting illness > Past medical history > Medication history >Allergies > Social and Family hx | S= Subjective |
| SOAP Format Includes: > Vital signs > Physical findings (PE) > Lab test results > Serum drug concentrations > Various diagnostic results (ECG, X-ray, biopsy) | O= Objective |
| SOAP Format Includes: > Medical problems (diagnosis) > DRPs > Clinical progress ( ex. Gastritis- resolved) | A= Assessment |
| SOAP Format Includes: > Add/remove/ change drug > Dosage modification > Communication with pt & health care provider > Monitoring and Counselling | P= Plan |
| “IAO” Format | >I= care issues similar to A in the SOAP > A= action (“pharm care action”) similar to P in the SOAP > O= outcome To document the outcome of the action carried out |