Pharmacy SOAP Note

Date/Time: [date and time of encounter]

Pharmacist: [name, credentials, service/team]

Encounter Type: [inpatient / ambulatory / ED]; [consult / follow-up]; [in-person / phone / video]

Reason for Note: [primary consult question or purpose]

Subjective

[Chief concern or consult question with relevant patient-reported context] (1–3 sentences; include direct quotes only when they inform medication decisions.)

• [Source of medication history and reliability] (Specify if not directly from patient; document limitations if uncertain.)
• [Current medication list as actually taken] (Include Rx, OTC, and supplements with name, strength, route, frequency, and timing patterns when relevant.)
• [Adherence patterns and barriers] (Cost, access, side effects, technique, beliefs. Only include if explicitly assessed.)
• [Last doses of high-risk medications] (Include date/time for agents requiring timing context; omit if not relevant.)
• [Medication access or insurance constraints] (Formulary status, prior authorization needs, copay, preferred pharmacy.)
• [Allergies and intolerances with reaction type and severity] (If not assessed, document that limitation rather than stating NKDA.)
• [Pertinent medical or social history] (Include only if directly relevant to medication decisions, e.g., renal/hepatic disease, pregnancy, substance use.)

Objective

• [Vital signs and anthropometrics] (Include height/weight for dosing calculations; dates/times for time-sensitive values.)
• [Renal and hepatic function] (SCr, eGFR, LFTs with dates.)
• [Pertinent labs informing therapy] (e.g., A1c, INR, CBC, BMP; include dates.)
• [Drug concentrations] (Sampling time relative to dose and therapeutic targets.)
• [Microbiology results] (Cultures and susceptibilities with source and collection date; omit if not applicable.)
• [Administration considerations] (MAR issues, missed doses, IV access, feeding tube, NPO status; include only when relevant to encounter.)
• [Home monitoring data or refill history] (For ambulatory settings; include time frame and source.)
• [Medication reconciliation sources and discrepancies] (Briefly list sources used and summarize clinically significant discrepancies identified.)
• [Missing key data needed for decision-making] (State constraint and plan to obtain.)

Assessment

[Overview of patient context and highest-priority medication therapy concerns] (Ensure conclusions are traceable to documented Subjective/Objective data.)

1. [Problem 1]: [diagnosis/indication and current status]

   • [Current related medication(s)]
   • [Medication therapy problem(s)] [indication / effectiveness / safety / adherence-access / monitoring gap]
   • [Pertinent S/O data supporting assessment] (Cite specific values, dates, or patient statements.)
   • [Clinical rationale and benefit–risk considerations] (Include patient-specific factors: organ function, interactions, preferences, goals.)

2. [Problem 2]: [diagnosis/indication and current status] (Add additional problems as needed.)

   • [Current related medication(s)]
   • [Medication therapy problem(s)] [indication / effectiveness / safety / adherence-access / monitoring gap]
   • [Pertinent S/O data supporting assessment]
   • [Clinical rationale and benefit–risk considerations]

Plan

1. [Problem 1 Plan]:

   • [Medication action] [start / stop / change / continue]; [drug, dose, route, frequency, duration] (Adjust for organ function as applicable.)
   • [Monitoring plan] (What to monitor, when, target values, thresholds for action; include TDM timing/targets when relevant.)
   • [Safety precautions] (e.g., hypoglycemia plan, bleeding precautions; omit if none indicated.)
   • [Authority and communication] [performed under protocol/CPA / recommended to prescriber]; [who contacted]; [accepted / declined / pending]; [orders placed]
   • [Patient education] (Content covered, method, interpreter use, teach-back result; medication list provided [yes / no].)
   • [Transitions-of-care plan] (Reconciled changes with rationale, dispensing pharmacy, prior authorization steps, post-discharge follow-up; include only for TOC encounters.)
   • [Follow-up plan] (Timeframe, responsible party, goals for next encounter.)

2. [Problem 2 Plan]: (Mirror structure above.)

   • [Medication action]
   • [Monitoring plan]
   • [Safety precautions]
   • [Authority and communication]
   • [Patient education]
   • [Transitions-of-care plan]
   • [Follow-up plan]

Pharmacist Signature: [electronic signature with credentials]

(When required information is unavailable, document limitations and source constraints rather than omitting. Avoid default negatives such as "denies bleeding" or "NKDA" unless explicitly assessed. Clearly distinguish actions performed under protocol/CPA from recommendations made to prescribers.)