PPCP Final (Spring)

resolved

therapeutic goals achieved for the acute condition; discontinue therapy

stable

therapeutic goals achieved; continue the same therapy for chronic disease management

improved

progress is being made in achieving goals; continue the same therapy because more time is required to assess the full benefit of therapy

partial improvement

Progress is being made, but minor adjustments in therapy are required to fully achieve the therapeutic goals before the next assessment

unimproved

Little or no progress has been made, but continue the same therapy to allow additional time for benefit to be observed

worsened

A decline in health is observed despite an adequate duration using the optimal drug; modify drug therapy (eg, increase the dose of the current medication, add a second agent with additive or synergistic effects)

Failure

Therapeutic goals have not been achieved despite an adequate dose and duration of therapy; discontinue current medication(s) and start new therapy

Expired

The patient died while receiving drug therapy; document possible contributing factors, especially if they may be drug related

-Medication name

-Formulation

-Route

-Dose

-Frequency

-Length of therapy (if appropriate)

What MUST be included in the pharmacological recommendation section of a SOAP note?

-Should be specific to patient

-Realistic for patient

-Involve shared-decision making

What should be included in the non-pharm recommendation section of a SOAP note?

rationale

-Explanation of why you did what you did

-Why did you choose this drug class over other drug classes?

-Why did you choose this specific drug versus others in the class?

Therapeutic Monitoring

"How do I know this med is working?"

Adverse Event Monitoring

"Is the tx causing harm to the patient"

NO

Is adverse event monitoring just listing side effects?

S-Subjective

O-Objective

A-Assessment

P-Plan

What does SOAP stand for?

global initiative for asthma

What does GINA stand for?