Pass the SOAP: Shifting from SOAP to Consult Notes for Clinical Documentation in Pharmacy Students

Abstract

Objective. Clinical documentation is an important element of patient care that pharmacy students traditionally learn through Subjective-Objective-Assessment-Plan (SOAP) notes. In clinical practice, pharmacists often document more succinctly both in regard to length and time; utilizing formats such as consult notes. The objective of this study was to assess consult note assignments for third-year pharmacy students (P3).

Methods. Consult note assignments were implemented in a P3 skills laboratory course by converting SOAP notes to consult notes. The series began with an introduction and a practice consult note. Four graded notes were then completed throughout the semester with time allotted for writing decreasing throughout the semester. To assess the series, grades and estimated time for completion were collected for each graded note. A pre-post survey assessed student self-confidence in: 1) overall documentation, 2) specific elements of consult notes, and 3) concerns related to writing. Friedman’s tests were utilized to compare grades and time. Wilcoxon Signed Rank tests were used to compare self-assessments.

Results. Median consult note grades were: 92%, 88%, 80%, and 90% for each note. Median time for completion were: 75 minutes, 120 minutes, 60 minutes, and 60 minutes. Student self-confidence in writing consult notes significantly increased as did five of the six individual elements.

Conclusion. The consult note assignments allowed students to practice documenting patient care in a succinct format with consideration for time efficiency. Further work should evaluate best pedagogies for teaching documentation skills and assess the impact on performance during advanced pharmacy practice experiences.