大切なのはここ⇒Only relevant information should be captured.

例えば；

ーlocation, severity, onset, associated symptoms and factors that improve/exacerbate the symptoms

diagnosis, surgical procedures

ーdiet, exercise, alcohol, cigarettes, social supports(whether the consumer lives at home alone/with family)

【O】‐Objective Information

例えば；

ーMedication list

ーMedication management - a perception of their adherence to medicines

ーAdverse drug effects

ーVital signs - BP, HR, weight, height and BMI (if the information is available)

ーLaboratory values/diagnostic test results (if you have the access to pathology results)

【A】‐Assessment

例えば；

ーan explanation of your recommended interventions and treatment goals and desired outcomes for the patient.

ーWhat might negativeky impact on the patient's progress.

ーProblems

ーMadication-related problems - adverse reactions, dosing discrepancies, missing therapies, medicines without an obvious indcation, drug interactions, complementary medicines and untreateddiseases, drug selection problems, over- or under- dosing, compliance, undertreting, monitoring, education or information, non-cinical information and toxicity or adverse drug effects.

【P】‐Plan

Goal - expected/desired outcomes resulting rom a change in medication management

Monitoring, reiew and referrals

Education or counselling provided

実際に、英語版SOAPの例がこちら↓