SOAP Note Process Checklist

Basic Components of Note

Beginning of note:

• Note title
• Date written
• Time written

End of note:

• Writer’s name/signature
• Writer’s title
• Writer’s phone number
• No grammatical errors (incomplete sentences allowed)
• Succinct phrases used
• No spelling errors
• Appropriate medical terminology
• Only approved abbreviations
• No patient identifiable information including initials (per Drake’s rules only)
• Information appropriately labeled (mg/dl, mm Hg, etc)

Subjective Information

• Demographic Informations
• Chief complaint/Reason for Encounter
• HPI
• Pertinent social history
• Pertinent family history

Subjective or Objective Information Depending on Source

• Current medication list
• Medication list includes drug, dose, route, directions and, if applicable, duration
• Assessment of medication adherence
• Pertinent allergies
• Pertinent past medication history
• Pertinent vital signs, labs or other tests

Checkpoint!
Is there any objective information in S?
Is there any subjective information in O?
Is there only information pertinent to A and P listed in S and O?
Are sources of information stated? 

Assessment

• Statement of drug therapy problem being addressed (using 7 Drug Therapy Problems*)
• Brief reasoning to support the need to address the selected drug therapy problem
• Goals of therapy related to selected drug therapy problem
• Pertinent therapeutic alternative(s) including pros and cons of each alternative

Checkpoint!
Is your statement of the drug therapy problem appropriate for communication with other health care providers? If not, write an additional statement of the drug therapy problem for communication with other health care providers:

• Use appropriate interprofessional language
• Clearly state information
• Be succinct

Plan

• Actions taken and/or recommendations
• Medication recommendations include drug, dose, route, directions and, if applicable, duration
• Brief description of any counseling points/patient education provided
• Monitoring component includes:
• Specific parameters to monitor therapeutic efficacy
• Specific parameters to monitor medication safety
• Person(s) responsible
• Assessment of patient understanding and agreement with plan
• Follow-up component includes:
• Purpose of follow-up
• Method of contact
• Person(s) responsible
• Timeframe
• Brief contingency plan if goals of therapy not reached

Checkpoint!
Does the plan address only the selected drug therapy problem?
Is no new subjective or objective information introduced in A or P?

*Tomechko MA, Strand LM, Morley PC, Cipolli RJ. Q and A from the pharmaceutical care project in Minnesota. Am Pharm. 1995;NS35(4): 30-9.