CLPA - Clinical Problem Solving and Documentation

SOAP

Subjective data, objective data, assessment, plan

Patients go to providers

__ when they have a problem (or several) and desire their help in solving it

Patients may want to discuss: Symptoms, questions, follow-ups, provision of drug product

Symptom

An unpleasant phenomenon or departure from the normal in structure, function, or sensation as experienced by the patient that is indicative of disease

Follow up

• Need for continuing care or monitoring of an acute or chronic problem

• When pt should be next be seen for re-assessment

• Any suggested referral to another health care provider should also be

Question

self-perceived knowledge deficit in a patient

Data types

Subjective, objective

Subjective

Aka the history

• Data that the patient tells you about himself/herself

• Mostly unverifiable; involves the pt’s perceptions and recollection

• May be provided by someone other than the pt

• Usually a family member or friend

• May be necessary if the pt cannot communicate effectively or has memory deficits

The history (aka subjective data)

• Some information about the patient’s __ may be obtained from the medical record

• Has many components or sections

Objective

• Any measurable or verifiable information we can collect about a pt

• Physical exam with vital signs

• Laboratory tests

• Radiological studies (x-rays, CT scans, etc.)

• Other types of diagnostic tests (pulmonary function tests, electrocardiograms, etc.)
  

Collect and analyze data

How do we figure out what to do with a patient? __ about the patient in a systematic way so we can make an assessment

Requires significant fund of knowledge on our part (along with formulation of a plan)

Forms of useful knowledge

• Memorized facts

• Understanding of processes and mechanisms

• Tasks or procedures (including communication)

• finding information - scientific literature

Memorized facts

Can be recalled immediately (classes of drugs, indications, common dosages, frequent ADRs, etc)

Understanding of processes

__ and mechanisms: (physiologic, pharmacologic, pathophysiologic, etc.) Allow us to work through a complex problem in a patient

Finding information

Through awareness of the methods used in the scientific literature to assist us in solving a problem

Plan

Steps that we (and the patient) will perform to improve his/her problem(s)

Formulated for the patient after making an accurate assessment

Plan Elements (Actions)

Drug therapy, nonpharmacological therapy, therapeutic lifestyle modifications, patient education, patient monitoring, follow up

Drug therapy

includes the drug name, dose frequency, and duration

may involve stopping, changing, or altering the dose of a drug the patient is currently receiving

may include alternative drug treatment options

Nonpharmacologic therapy

exs. apply heat or ice, fall prevention modalities, supplemental O₂

Therapeutic lifestyle modifications

Encouraging the pt to change dietary, exercise, etc. habits as needed to improve the pt’s health

Patient education

Discussion regarding drug admin techniques, potential ADRs, home monitoring, critical disease sxs, health maintenance issues, etc.

Patient monitoring

Methods and timing for determination of drug efficacy, ADRs, disease progression, etc

Goals of the Plan

• Cure disease or minimize progression/adverse sequelae

• Provide relief from unpleasant symptoms

• Maintain or improve patient’s functionality

• Maximize quality of life (QOL)

• Augment patient’s ability to participate in his/her treatment or recovery

• Simplify/increase efficiency of therapeutic modalities (while maintaining efficacy)

• Maintain good health after recovery

Generating hypotheses process

Ruling out (a hypothesis)

To show that it is extremely unlikely based on the collected data

Ruling in (a hypothesis)

To show that it is very likely (or certain) based on the collected data

Differential diagnoses

Each diagnosis (or problem)