Journal of Applied Pharmaceutical Science Vol.

11(10), pp 001-006, October, 2021

Available online at http://www.japsonline.com
DOI: 10.7324/JAPS.2021.1101001
ISSN 2231-3354

Development and validation of A-SOAP notes: Assessment of

efficiency in documenting patient therapeutic records

Pooja Sudarsan , Aishwarya Gowda Murulya Balakrishna, Jerlin Anusha Rajasingh Asir, Deepan Balu, Sadagoban Gopal
Krishnamoorthy , Swathi Swaroopa Borra*
Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, Tamil Nadu, India.

ARTICLE INFO ABSTRACT

Received on: 05/05/2021 Subjective, Objective Assessment and Plan (SOAP) notes have a major significance in healthcare; but there is no
Accepted on: 20/07/2021 standard format for documentation. The objective of this study is to develop and validate advanced SOAP (A-SOAP)
Available Online: 03/10/2021 notes for effective documentation of patient health status. “A-SOAP” was designed based on the results of several
published studies. 34 postgraduate Doctor of Pharmacy students were randomized and administered with two SOAP
notes, case scenario, and a feedback form. The SOAP notes were evaluated using a grading tool. Paired t-test and
Key words:
one-way analysis of variance were carried out to measure the difference in scores and its significance. The scores
SOAP notes, pharmacy,
of A-SOAP were more noteworthy (57.94 ± 15.86) in comparison to SOAP 1 (14.49 ± 12.95) at p < 0.001. The
documentation, validation,
distribution of scores was also significantly different among participants of various academic years. The efficiency in
experiential education,
problem identification and documentation had improved with A-SOAP.
medical record.

INTRODUCTION role in providing pharmacotherapeutic recommendations that

“SOAP,” which stands for subjective, objective, include treatment alternatives, drug interactions, major side
assessment, and plan, is a tool used for documenting patient care effects, and dose adjustments (Mowery et al., 2012). Therapeutic
notes in a structured and organized way. It was developed in the notes also help in tracking patient prognosis on a daily basis
year 1960 by Dr Lawrence Weed at the University of Vermont (O’Sullivan and Odegard, 2013; Vijayakumar, 2016). Crausman
as a part of the problem-orientated medical record (Weed, 1968; (1998) had described the use of this instrument to capture student
Wright et al., 2014). In recent years, documentation of patient the perspectives in clinical decisions. It helps in mapping different
information during the therapeutic hour has gained importance components of a medical record (Crausman, 1998).
in treatment optimization (Podder et al., 2020). Healthcare The Accreditation Council for Pharmacy Education
providers often feel frustrated to decide what to include and what Accreditation Standards states that a pharmacy student must master
not to include in these notes. Structured therapeutic notes help the skills of documentation and provide recommendations to the
in accountability, delivery of appropriate service, and support healthcare team for effective patient care (Accreditation Council
clinical decisions (Cameron and Turtle Song, 2002). SOAP notes for Pharmacy Education, 2015). Trainings on documentation must
also serve as a source of communication that is widely used be prioritized for students. SOAP notes have to be reviewed and
by various healthcare professionals, such as physician, nurse, modified periodically (Lisenby et al., 2018; Sherman et al., 2019).
physiotherapist, pharmacists, etc. Pharmacists play an integral Unavailability of a standardized SOAP note is one of
the challenges faced by healthcare professionals. Some of the
modified versions of SOAP are (a) SOAPIE “or” SOAPIER (I,
Intervention; E, Evaluation of the interventions; R, Revisions
*
Corresponding Author made to the existing plan) (Using SOAP, SOAPIE, and SOAPIER
Swathi Swaroopa Borra, Department of Pharmacy Practice, JSS College of Formats, 1999); (b) S-SOAP (a tool exclusively used in psychiatry
Pharmacy, JSS Academy of Higher Education & Research, Ooty, Nilgiris, to include systemic complexities into practice) (Mitsuishi et al.,
Tamil Nadu, India. E-mail: swasasree @ jssuni.edu.in

© 2021 Pooja Sudarsan et al. This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License
(https://creativecommons.org/licenses/by/4.0/).
002 Sudarsan et al. / Journal of Applied Pharmaceutical Science 11 (10); 2021: 001-006

2016); (c) Kibble et al. (2006) had reframed SOAP as subjective, such as A-SOAP note and feedback questionnaire. As there is no
objective, and assessment of physiology; it was used as a modality gold standard tool for documentation, the newly designed SOAP
for teaching medical physiology; (d) SOAP has also been note (A-SOAP) was validated using a basic template (SOAP 1).
combined with other teaching methods such as peer-evaluation SOAP 1 consisted of general headings: “subjective,” “objective,”
and self-assessment which have been proven to be effective in “assessment,” and “plan.” Feedback was collected from the
improving the quality of student assessments (Storjohann et al., faculties handling Doctor of Pharmacy (Pharm D) graduates
2019). using SOAP 1. They stated that the responses of students on
A poorly organized SOAP note can give rise to SOAP 1 were indefinitely varied due to their vague structure
misinterpretation of information. This increases the need for a and did not meet the purpose of documentation clearly. Hence,
validated SOAP note that is concise, comprehendible, less time- a new SOAP note was framed to overcome these limitations. An
consuming, confidential, and legitimate (Santiago et al., 2016). electronic search on PubMed, Scopus, and Cochrane CENTRAL
Studies have been conducted by healthcare professionals to was conducted by three reviewers: Reviewers 1, 2, and 3. A
evaluate the accuracy and appropriateness of SOAP notes. Seo total of 52 articles were obtained wherefrom four pharmacy
et al. (2016) had observed incompleteness and inaccuracy in SOAP notes were identified (Oregon State University, 2017;
the SOAP notes filled by medical students. Additionally, studies University of Alberta, 2002; University of Florida, 2012; Virginia
pertaining to validation and evaluation of SOAP notes for clinical Pharmacists Association, 2019). Full text of the SOAP notes was
pharmacists are limited. This increases the need for devising and retrieved and reviewed by two reviewers (Reviewer 4 and 5).
evaluating an effective documentation tool that is applicable to all The selected SOAP notes were dismantled and the significance
case scenarios. The objective of this study is to design a pharmacy of each component was critically reviewed. The components that
SOAP note and validate its quality in improving the documentation were specific for documenting pharmacy notes were selected and
skills of pharmacy students pursuing clinical rotations. included. All discrepancies were sorted out by Reviewer 6. The
MATERIALS AND METHODS review comments which were used in creating A-SOAP are stated
in Table 1. The newly designed SOAP note was considered to be an
Phase I advanced version since all relevant components were included in
A prospective study was conducted in a pharmacy a concise manner. The “Subjective” and “Objective” components
school from November 2019 to February 2020, wherein a are similar to any physician’s SOAP notes. “Assessment” entailed
qualitative approach was incorporated to validate the caliber of a subheadings which can be thought-provoking for students to
newly designed advanced SOAP (A-SOAP) note for pharmacists. identify interventions and improve the quality of documentation.
Phase I included the preparation of relevant study documents, A-SOAP was drafted based on several criteria identified by the

Table 1. List of SOAP notes and its components (Assessment and Plan) added in A-SOAP.
List of published SOAP
forms from pharmacy Components of respective university SOAP notes Components added in A-SOAP
schools
Virginia Pharmacists A: Diagnosis or differential diagnosis P: Drug therapy, efficacy, and toxicity parameters to
Association detect drug-related ADRs and therapeutic outcomes,
P: Drug therapy, efficacy, and toxicity parameters to
patient education, specific goals, and alternative
detect drug-related adverse drug reactions (ADRs) and
therapies.
therapeutic outcomes, patient education, specific goals,
and alternative therapies.
Oregon state University A: Prioritized problem list and drug-related problems, P: Treatment plan, education and counseling,
justification for drug-related problems monitoring, follow-up, and referrals
P: Treatment plan, education and counseling,
monitoring, follow-up, and referrals
University of Alberta A: Diagnosis or differential diagnosis P: Goals of therapy, drug therapy recommendations,
monitoring parameter (safety and efficacy), follow-up,
P: Goals of therapy, drug therapy recommendations,
name and sign of student, and preceptor with contact
monitoring parameter (safety and efficacy), follow-up,
number
name and sign of student, and preceptor with contact
number
University of Florida A and P: Appropriate data from patient medication- A and P: Appropriate data from patient medication-
related to evidence-based related to evidence-based
Pharmacokinetic monitoring, appropriateness of dose Pharmacokinetic monitoring, appropriateness of dose
calculation, evidence-based medication therapy calculation, evidence-based medication therapy
Cost-effective drug products, medication-related Cost-effective drug products, medication-related
problems, and treatment plan problems, and treatment plan

A = Assessment; P = Plan.
 Sudarsan et al. / Journal of Applied Pharmaceutical Science 11 (10); 2021: 001-006 003

authors and it is applicable to all hospital settings. The assessment were asked to fill two SOAP notes for the same case scenario. The
section in A-SOAP was categorized based on the most commonly time taken to fill out both the SOAP notes was noted. They were
encountered interventions like disease, drug, and administration- also asked to provide feedback pertaining to A-SOAP. This study
related problems. A suitable justification has to be stated to cleared ethical approval and informed consent was obtained from
every problem identified. Provision was provided to prioritize all study participants.
the interventions. “Plan” was segregated into goals of therapy,
therapeutic recommendation, and patient education. The basic Phase III
structure of A-SOAP is provided in Table 2. Both SOAP notes were evaluated using a rubric grading
A feedback questionnaire was carefully crafted in order tool published by Sherman et al. (2019). The grading tool aimed
to capture the student comments on A-SOAP (Sherman et al., 2019; to evaluate the efficiency in reporting interventions. The number of
Storjohann et al., 2019). These comments can help in improvising interventions of both SOAP notes were compared and analyzed. A
and assessing the quality of the newly designed SOAP note. The better score indicated proficient understanding and reporting skills.
questionnaire was developed to capture the relevancy, simplicity, An answer key was prepared and circulated among the evaluators.
and efficiency of the SOAP note. The feedback was on a Likert- Instructions were provided to them on different components of the
type scale graded as strongly agree, agree, disagree, and strongly grading rubric. All evaluators involved in grading the SOAP notes
disagree. The questionnaire has provisions for comments and were blinded. The grading tool was used to assess the quality of
suggestions. interventions, therapy goals, and plans set by the pharmacist. Points
were allotted for prioritization of interventions, providing patient-
Phase II specific education, listing out the monitoring parameters, and
Postgraduate Pharm D students from fourth to sixth year providing appropriate recommendations to the problems identified
were eligible to participate in the study. A total of 34 students on a scale of 1–5. Points were awarded for additional interventions
were randomly selected using a computer-generated sequence identified. The overall score was in 100 points, which was statistically
from fourth, fifth, and sixth years. The following objectives were analyzed. An overview of the study design is shown in Figure 1.
planned to be met in the course of the study: ability to interpret
the case scenario, documentation of case details and interventions, Data analysis
assessment of the quality of interventions, and time taken for Paired t-test was used to compare the scores between
documentation. The investigator had addressed all the participants the SOAP notes. A p-value less than 0.05 was considered to be
on the study objectives, the constituents of A-SOAP, and the statistically significant. One-way analysis of variance (ANOVA)
study procedure. A common case scenario was prepared and was carried out to determine the difference in the means of
administered to the participants. The case scenario included patient independent groups. This was followed by a post-hoc analysis to
demographics, complaints on admission and relevant histories, rule out which specific group differed from others. The positive
allergies, immunization status, diagnosis, laboratory/non- and negative opinions provided by students were identified and
laboratory parameters, and day-to-day treatment chart. Students categorized by conducting a feedback analysis. The scores were

Table 2. Structure of A-SOAP.

Subjective
1 Patient demographics (chief complaints, past medical, past medication, social, and family history, provisional diagnosis)
Objective
1 Objective data (height, weight, body mass index, altered lab parameters)
Assessment
(provide justification or evidence)
1 Disease-related problems (condition untreated, prophylactic therapy, immunization, scales to be administered)
2 Monitoring parameters (laboratory, non-laboratory, therapeutic drug monitoring)
3 Administration errors (extravasation, dilution, rate, dose, time)
4 Rationality for antibiotic use (choice of antibiotic, sensitivity, resistance pattern, etc.)
Drug-related problems (indication, side-effects, efficacy, adherence, interaction/duplication, contraindication,
5
dose, dosage form, frequency, duration, route of administration, and cost-effectiveness)
6 Prioritize interventions
Plan
1 Goals of therapy (prioritize goals)
2 Therapeutic recommendation (include drug dose route regimen and duration)
3 Patient education/counseling (disease, drug, lifestyle modification)
4 Monitoring for safety and efficacy (include frequency interval follow-up plan)
004 Sudarsan et al. / Journal of Applied Pharmaceutical Science 11 (10); 2021: 001-006

Figure 1. Study flow diagram.

Table 3. Overview of SOAP 1 and A-SOAP overall scores.

Parameter Category Mean ± SD
Overall scores SOAP 1 14.49 ± 12.95
A-SOAP 57.94 ± 15.86
A-SOAP score distribution based on curriculum level Fourth-year Pharm D 66.4 ± 12.6
Fifth-year Pharm D 43.9 ± 16.7
Sixth-year Pharm D 63.7 ± 8.9

analyzed using IBM Statistical Package for the Social Sciences is due to the varied understanding of the case scenario. In total,
(SPSS) (V.21.0; SPSS Inc., Chicago, IL). The Likert scale was 76% of the respondents rated that A-SOAP had increased their
analyzed using Microsoft excel version 2007. ability to identify interventions. Some of the comments stated by
the participants were: (a) the triggering questions and subheadings
RESULTS AND DISCUSSION
under assessment and plan sections were thought-provoking. (b) It
A total of 34 participants from fourth, fifth, and sixth had enabled them to identify interventions that were specific to the
year Pharm D had completed the study. The scores of both the case. However, they found A-SOAP to be more time-consuming
SOAP notes were presented as mean ± standard deviation. Paired in comparison to SOAP 1. The results of the feedback analysis are
t-test was carried out to measure the significance in the difference
presented in Table 4.
in scores (p < 0.05). On average, the score attained using
Pharmacy profession is taking a stride toward direct
A-SOAP was greater (57.94 ± 15.86) than SOAP note 1 (14.49
patient care. Hence, there is an increased concern in their ability
± 12.95). This difference (−43.44, 95% CI = −48.73, −38.15)
to document and communicate clinical situations. Nguyen et al.
was significant (t = −16.70, p = 0.000). A statistically significant
difference in the scores of A-SOAP between fourth, fifth, and (2019) had examined student performance in documenting SOAP
sixth years was identified by one-way ANOVA (F = 9.907, p = notes in different semesters. Two SOAP notes filled at different
0.000). Tukey’s post-hoc test indicated that the scores of A-SOAP time points were scored and analyzed. A non-significant p-value
was significantly higher among the fourth-year (66.4 ± 12.6, p = indicated adequate performance at various time points. The skill
0.002) and sixth-year students (63.7 ± 8.9, p = 0.001) compared of documentation can be developed through a well-structured
to the fifth-year students (43.9 ± 16.7). There was no statistically SOAP note. Recording patient health status in SOAP notes must
significant difference between the fourth and sixth years. The be initiated during clinical rotations of students. This can boost
scores are summarized in Table 3. their self-confidence and make them more competent in providing
The average time taken by fourth-year students to fill patient care (Chan et al., 2019). The framework of A-SOAP was
A-SOAP was 45 minutes. Both fifth and sixth years had taken an found to be a methodical learning tool for students pursuing
average of 15–20 minutes. This difference in time consumption clinical rotation.
 Sudarsan et al. / Journal of Applied Pharmaceutical Science 11 (10); 2021: 001-006 005

Table 4. Student feedback analysis on A-SOAP.

Questions Strongly agree (%) Agree (%) Disagree (%) Strongly disagree (%) Total (%)
The objective of A-SOAP was stated clearly and met 88% 12% 0% 0% 100%
The format was easy to follow 62% 35% 0% 3% 100%
Components of the A-SOAP were relevant and useful 79% 21% 0% 0% 100%
This SOAP note increased my ability in identifying 76% 15% 9% 0% 100%
interventions
The time allocated for documentation was sufficient 38% 47% 9% 6% 100%
Thoughtful critique of patient–drug therapy 74% 24% 0% 3% 100%
Efficiency in the summarization of case scenario 76% 21% 3% 0% 100%
Overall rating for A-SOAP 68% 32% 0% 0% 100%

In general, documentation of patients’ demographics and the case scenario, summarizing, providing case-specific mitigation
treatment enables continuity of care and enhances interprofessional strategies, writing, and documentation were upgraded in A-SOAP.
communication. Clinical records help to audit the quality of The limitations in this study include smaller sample
healthcare services and can also be used for investigation of serious size and difference in the understanding of case scenario as
incidents, patient complaints, and compensation. Complete up-to- students’ participation was from three different years; however,
date clinical notes will ensure that proper information is provided this problem was overcome by providing a case that was a part of
to all relevant healthcare workers to optimize treatment plans. curriculum. A-SOAP note is applicable to all Pharm D students
This will favor patients to reduce the burden of repetitive tests who are undertaking clinical rotations. The future prospect of this
or by eschewing incorrect diagnosis and receiving inappropriate study is evaluating its reliability by conducting a similar study
treatment (Mathioudakis et al., 2016). In this study, a grading with different case scenarios.
rubric was used to evaluate the performance of students. This tool
was prepared by Sherman et al. (2019), in their study, to assess CONCLUSION
patient care skills among pharmacy students using SOAP notes. The quality of documentation had significantly improved
It was effective and feasible in accessing the improvement in in the A-SOAP. A-SOAP can be used as an effective tool for
documentation skills, objectively. documenting patient therapeutic records and communicating the
In the present study, a significant difference in the same to fellow healthcare providers. In the future, the reliability
performance of fourth-, fifth-, and sixth-year students was found. of A-SOAP can be tested and made specific to therapeutic areas
This could be due to unequal distribution of sample size and varied by testing on different case scenarios. It can also be used in
understanding of case scenarios among participants. The students’ combination with other teaching modalities to address nuances in
ability of filling and understanding A-SOAP was considerably documentation.
better in comparison to SOAP 1. The writing ability of the study
participants was assessed in this study. ACKNOWLEDGMENTS
A-SOAP consisted of questions that were easier to The authors express their gratitude toward all students
comprehend and had enhanced their capability in identifying drug- who had participated in this study.
related problems. It was also time-consuming as stated by the study
participants. Critical thinking is required to fill the components AUTHORSHIP CONTRIBUTIONS
of the assessment section; hence, the average time spent by all SSB: conceptualization, validation, supervision, project
study participants to provide an evidence-based care plan was 45 administration, writing, review and editing, and approval of final
minutes. Spending passable time with patients is important for a draft. PS: methodology, investigation, formal analysis, writing of
thorough understanding of their medical condition and treatment. the original draft, and approval of final draft. AG: methodology,
Participants found that the A-SOAP was more specific and helped writing of the original draft, and approval of final draft. JA:
to understand the patient’s disease condition, which favored in visualization, methodology, investigation, and approval of final
framing a plan. This study had also observed that documentation draft. DB: investigation, data curation, and approval of final
of patient details was more specific with A-SOAP. draft. SGK: resources, writing, review and editing, approval of
Random selection of study participants and application final draft, and project administration. All the listed authors have
of a uniform answer key for evaluation had prevented the agreed to be accountable for all aspects of the work.
occurrence of bias with this study. In addition to this, the SOAP
note was prepared such that it is applicable to all hospital sectors. LIST OF ABBREVIATIONS
All participants were given orientation to the components of SOAP: subjective, objective, assessment and plan;
A-SOAP and the grading tool used for evaluation. This ensured A-SOAP: advanced subjective, objective, assessment and plan;
unvarying understanding among the study participants. Based on Pharm D: Doctor of Pharmacy; ANOVA: analysis of variance;
the feedback provided by the evaluators, skills such as interpreting TDM: Therapeutic Drug Monitoring.
006 Sudarsan et al. / Journal of Applied Pharmaceutical Science 11 (10); 2021: 001-006

CONFLICT OF INTEREST pharmacy.oregonstate.edu/files/soap_rubric_and_components_-_final_

nov_2017.pdf (Accessed 30 April 2020)
The authors have no potential conflicts of interest to
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