10 Common Pharmacy SOAP Note Examples

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List of cases

1. Medication Therapy Management
2. Anticoagulation Monitoring
3. Diabetes Management
4. Hypertension Control
5. Asthma/COPD Review
6. Pain Management
7. Heart Failure Monitoring
8. Lipid Management
9. Psychiatric Medication Review
10. Antimicrobial Stewardship

1. Medication Therapy Management

Description

The patient presents for comprehensive medication therapy management review, focusing on medication reconciliation and optimization of therapy.

SOAP Note

Patient Name: Richard Thompson

Date of Visit: 09/01/2024

Subjective

Richard Thompson, a 72-year-old male, presents for medication therapy management review. Reports concerns about multiple medications and side effects. Takes medications from multiple prescribers. Primary complaints include morning dizziness, occasional confusion about medication timing, and cost concerns. Uses local pharmacy and mail order services.

Objective

• Vital Signs:
  • BP: 134/78 mmHg
  • HR: 76 bpm
  • RR: 16/min
• Current Medications:
  • Lisinopril 20mg daily
  • Metformin 1000mg twice daily
  • Atorvastatin 40mg daily
  • Aspirin 81mg daily
  • Amlodipine 5mg daily
  • Omeprazole 20mg daily
  • Multiple OTC supplements
• Lab Values (2 weeks ago):
  • A1C: 7.2%
  • LDL: 82 mg/dL
  • eGFR: 58 mL/min
  • K+: 4.2 mEq/L
• Medication Adherence:
  • Morisky Score: 6/8 (moderate adherence)
  • Reports missing doses 1-2 times/week
  • Uses pill organizer inconsistently

Assessment

1. Medication Management Issues
   • Polypharmacy concerns
   • Adherence challenges
   • Potential drug interactions
2. Therapeutic Monitoring
   • BP well-controlled
   • Diabetes at goal
   • Renal function stable

Plan

1. Interventions:

   • Medication reconciliation completed
   • Recommend discontinuing duplicate supplements
   • Suggest timing adjustments for amlodipine
   • Duration: 45 minutes
   • CPT Code: 99605

2. Medication Adjustments:

   • Move amlodipine to bedtime
   • Consolidate supplement regimen
   • Continue other medications as prescribed
   • Consider pill organizer system

3. Patient Education:

   • Medication timing schedule provided
   • Side effect management strategies
   • Adherence tools discussed
   • Cost-saving options reviewed

4. Follow-up:

   • Schedule 3-month follow-up
   • Monitor BP readings
   • Track adherence improvements

2. Anticoagulation Monitoring

Description

The patient presents for routine warfarin monitoring and dose adjustment in the pharmacy anticoagulation clinic.

SOAP Note

Patient Name: Mary Wilson

Date of Visit: 09/02/2024

Subjective

Mary Wilson, a 68-year-old female with atrial fibrillation, presents for routine INR monitoring. Reports consistent medication adherence with no missed doses. Denies bleeding or bruising. No recent dietary changes or new medications. Reports upcoming dental cleaning next week. No other concerns reported.

Objective

• Vital Signs:
  • BP: 122/72 mmHg
  • HR: 78 bpm irregular
  • RR: 16/min
• Anticoagulation Data:
  • Current INR: 2.8 (Goal 2.0-3.0)
  • Previous INR (2 weeks ago): 2.4
  • Current warfarin dose: 5mg daily
  • Time in therapeutic range: 72%
• Recent Labs:
  • Hgb: 13.2 g/dL
  • Plt: 245,000/μL
  • Cr: 0.9 mg/dL
• Medication Review:
  • No new medications
  • No recent antibiotics
  • No OTC additions

Assessment

1. Anticoagulation Status
   • INR therapeutic
   • Stable dosing
   • Good adherence
2. Upcoming Procedure
   • Dental cleaning
   • Low bleeding risk
   • No bridging needed

Plan

1. Interventions:

   • INR monitoring completed
   • Dental procedure counseling
   • Duration: 30 minutes
   • CPT Code: 99211

2. Medication Management:

   • Continue current warfarin dose
   • No dose adjustment needed
   • Document stable INR trend
   • Review drug interactions

3. Patient Education:

   • Dental procedure instructions
   • Continue dietary consistency
   • Monitor for bleeding signs
   • When to seek care

4. Follow-up:

   • Schedule 2-week follow-up
   • Post-procedure check
   • Monitor INR stability

3. Diabetes Management

Description

The patient presents for diabetes medication management and monitoring in the pharmacy diabetes clinic.

SOAP Note

Patient Name: James Rodriguez

Date of Visit: 09/03/2024

Subjective

James Rodriguez, a 56-year-old male with type 2 diabetes, presents for medication management. Reports frequent hypoglycemic episodes (2-3/week) in late morning. Performs SMBG 2-3 times daily. Following recommended diet with some difficulty. Exercises 30 minutes, 3 times weekly. Reports good medication adherence but concerned about cost of medications.

Objective

• Vital Signs:
  • BP: 128/76 mmHg
  • HR: 74 bpm
  • RR: 16/min
  • Weight: 88 kg (down 2 kg from last visit)
• Glycemic Data:
  • A1C: 6.4% (down from 7.8% 3 months ago)
  • SMBG Log:
    • Fasting: 80-120 mg/dL
    • Pre-lunch: 60-85 mg/dL
    • Pre-dinner: 100-140 mg/dL
    • Bedtime: 110-150 mg/dL
• Current Medications:
  • Glimepiride 4mg daily
  • Metformin 1000mg twice daily
  • Empagliflozin 10mg daily
  • Lisinopril 20mg daily
• Labs (1 week ago):
  • SCr: 1.0 mg/dL
  • eGFR: 75 mL/min
  • K+: 4.3 mEq/L
  • LDL: 88 mg/dL

Assessment

1. Type 2 Diabetes
   • Improved glycemic control
   • Frequent hypoglycemia
   • Good medication adherence
2. Medication Safety
   • Sulfonylurea dose likely too high
   • SGLT2 inhibitor appropriate
   • No renal dose adjustments needed

Plan

1. Interventions:

   • Medication adjustment recommended
   • SMBG pattern review
   • Duration: 30 minutes
   • CPT Code: 99212

2. Medication Adjustments:

   • Decrease glimepiride to 2mg daily
   • Continue other medications unchanged
   • Review in 2 weeks for response
   • Consider further dose reduction

3. Patient Education:

   • Hypoglycemia management
   • SMBG timing review
   • Diet/exercise reinforcement
   • Medication cost resources

4. Follow-up:

   • Schedule 2-week follow-up
   • Continue SMBG monitoring
   • Track hypoglycemic events

4. Hypertension Control

Description

The patient presents for hypertension medication management and blood pressure monitoring in the pharmacy cardiovascular clinic.

SOAP Note

Patient Name: Patricia Brown

Date of Visit: 09/04/2024

Subjective

Patricia Brown, a 62-year-old female with hypertension, presents for medication review. Reports home BP readings consistently elevated despite medication adherence. Denies side effects from current medications. Following low-sodium diet. Reports increased stress at work. Using automated BP cuff at home.

Objective

• Vital Signs:
  • BP: 158/92 mmHg (average of 3 readings)
  • HR: 76 bpm
  • RR: 16/min
• Home BP Log (past 2 weeks):
  • Morning: 150-162/88-94 mmHg
  • Evening: 148-156/86-92 mmHg
  • Heart rate: 72-80 bpm
• Current Medications:
  • Lisinopril 20mg daily
  • Hydrochlorothiazide 25mg daily
  • Aspirin 81mg daily
• Labs (2 weeks ago):
  • Na+: 138 mEq/L
  • K+: 3.8 mEq/L
  • Cl-: 102 mEq/L
  • SCr: 1.1 mg/dL
  • eGFR: 68 mL/min

Assessment

1. Uncontrolled Hypertension
   • BP above goal (>140/90)
   • Adequate therapy not achieved
   • Good medication adherence
2. Cardiovascular Risk
   • Multiple risk factors
   • No end-organ damage
   • Lifestyle modifications in place

Plan

1. Interventions:

   • BP medication optimization
   • Home BP technique review
   • Duration: 30 minutes
   • CPT Code: 99211

2. Medication Adjustments:

   • Increase lisinopril to 40mg daily
   • Continue HCTZ unchanged
   • Monitor potassium closely
   • Consider adding CCB if needed

3. Patient Education:

   • BP measurement technique
   • Sodium restriction review
   • Stress management strategies
   • Medication timing review

4. Follow-up:

   • Schedule 2-week follow-up
   • Continue home BP monitoring
   • Track response to dose change

5. Asthma/COPD Review

Description

The patient presents for asthma/COPD medication management and inhaler technique assessment in the pharmacy respiratory clinic.

SOAP Note

Patient Name: Michael Stevens

Date of Visit: 09/05/2024

Subjective

Michael Stevens, a 45-year-old male with moderate persistent asthma, presents for medication review. Reports increased rescue inhaler use (3-4 times/day) over past month. Waking at night with symptoms 2-3 times/week. Denies recent respiratory infections. Notes seasonal allergies are worse. Concerned about inhaler technique.

Objective

• Vital Signs:
  • BP: 126/78 mmHg
  • HR: 82 bpm
  • RR: 18/min
  • SpO2: 97% on room air
• Respiratory Assessment:
  • Peak Flow: 350 L/min (65% of personal best)
  • Asthma Control Test Score: 16 (poor control)
  • Breath sounds: Scattered wheezing
  • Inhaler technique: Multiple errors noted
• Current Medications:
  • Fluticasone/Salmeterol 250/50 twice daily
  • Albuterol HFA prn
  • Montelukast 10mg daily
  • Cetirizine 10mg daily
• Adherence Review:
  • Controller medication use: 75% of prescribed
  • Technique errors with both inhalers
  • Reports cost not a barrier
  • Has spacer but rarely uses

Assessment

1. Poorly Controlled Asthma
   • Increased symptoms
   • Suboptimal inhaler technique
   • Seasonal component
2. Medication Use
   • Suboptimal adherence
   • Technique needs improvement
   • Appropriate therapy selection

Plan

1. Interventions:

   • Inhaler technique education
   • Action plan review
   • Duration: 45 minutes
   • CPT Code: 99213

2. Medication Adjustments:

   • Continue current medications
   • Reinforce proper technique
   • Add spacer device use
   • Consider peak flow monitoring

3. Patient Education:

   • Inhaler technique demonstration
   • Trigger avoidance strategies
   • Action plan review
   • When to seek care

4. Follow-up:

   • Schedule 2-week follow-up
   • Monitor symptom control
   • Track rescue inhaler use

6. Pain Management

Description

The patient presents for chronic pain medication review and monitoring in the pharmacy pain management clinic.

SOAP Note

Patient Name: Sarah Anderson

Date of Visit: 09/06/2024

Subjective

Sarah Anderson, a 58-year-old female with chronic lower back pain, presents for medication review. Reports average pain 6/10, worse with activity. Using prescribed medications as directed. Denies new neurological symptoms. Participating in physical therapy twice weekly. Reports adequate pain control but concerned about long-term medication use.

Objective

• Vital Signs:
  • BP: 132/78 mmHg
  • HR: 72 bpm
  • RR: 16/min
• Pain Assessment:
  • Current pain: 5/10
  • Average daily pain: 6/10
  • Worst pain: 8/10
  • Pain Interference Score: 6/10
• Current Medications:
  • Tramadol 50mg q6h prn
  • Gabapentin 300mg TID
  • Acetaminophen 1000mg TID
  • Cyclobenzaprine 10mg qhs prn
• Risk Assessment:
  • PDMP review: No concerns
  • Risk assessment score: Low
  • UDS: Consistent with prescribed
  • No aberrant behaviors

Assessment

1. Chronic Low Back Pain
   • Stable control
   • Appropriate medication use
   • Multimodal approach
2. Medication Safety
   • No red flags identified
   • Good adherence
   • No adverse effects

Plan

1. Interventions:

   • Medication review completed
   • Risk assessment updated
   • Duration: 30 minutes
   • CPT Code: 99212

2. Medication Management:

   • Continue current regimen
   • No changes needed
   • Monitor for continued efficacy
   • Consider gradual taper plan

3. Patient Education:

   • Non-pharmacologic strategies
   • Safe medication storage
   • Activity pacing techniques
   • Red flag symptoms review

4. Follow-up:

   • Schedule 1-month follow-up
   • Continue PT participation
   • Monitor function/pain levels

7. Heart Failure Monitoring

Description

The patient presents for heart failure medication optimization and symptom monitoring in the pharmacy cardiovascular clinic.

SOAP Note

Patient Name: Robert Johnson

Date of Visit: 09/07/2024

Subjective

Robert Johnson, a 70-year-old male with HFrEF (EF 35%), presents for medication review. Reports increased dyspnea with moderate activity and occasional orthopnea. Denies chest pain. Following 2g sodium diet. Daily weight monitoring shows 2 kg gain over past week. Good medication adherence reported.

Objective

• Vital Signs:
  • BP: 112/68 mmHg
  • HR: 68 bpm
  • RR: 20/min
  • SpO2: 95% on room air
• Heart Failure Status:
  • NYHA Class: II-III
  • Recent weight trend: 2 kg increase
  • Mild bilateral ankle edema
  • JVD not visible at 45°
• Current Medications:
  • Carvedilol 12.5mg BID
  • Lisinopril 20mg daily
  • Spironolactone 25mg daily
  • Furosemide 40mg daily
• Labs (1 week ago):
  • BNP: 450 pg/mL
  • K+: 4.5 mEq/L
  • SCr: 1.3 mg/dL
  • eGFR: 52 mL/min

Assessment

1. Heart Failure
   • Mild decompensation
   • Volume overload
   • Stable medications
2. Medication Optimization
   • Below target doses
   • Renal function stable
   • Electrolytes appropriate

Plan

1. Interventions:

   • Medication optimization
   • Symptom assessment
   • Duration: 30 minutes
   • CPT Code: 99213

2. Medication Adjustments:

   • Increase furosemide to 40mg BID
   • Consider carvedilol uptitration
   • Continue other medications
   • Monitor renal function

3. Patient Education:

   • Fluid/sodium restrictions
   • Daily weight monitoring
   • Symptom recognition
   • When to seek care

4. Follow-up:

   • Schedule 1-week follow-up
   • Monitor weight changes
   • Track symptom improvement

8. Lipid Management

Description

The patient presents for lipid management and cardiovascular risk reduction in the pharmacy lipid clinic.

SOAP Note

Patient Name: Linda Martinez

Date of Visit: 09/08/2024

Subjective

Linda Martinez, a 54-year-old female with hyperlipidemia and family history of premature CAD, presents for medication review. Reports good medication adherence but occasional muscle aches. Following Mediterranean diet. Exercises 3 times weekly. No chest pain or cardiovascular symptoms reported.

Objective

• Vital Signs:
  • BP: 126/74 mmHg
  • HR: 70 bpm
  • RR: 16/min
  • BMI: 27.8 kg/m²
• Lipid Panel (2 weeks ago):
  • Total Cholesterol: 220 mg/dL
  • LDL-C: 142 mg/dL
  • HDL-C: 48 mg/dL
  • Triglycerides: 150 mg/dL
• Current Medications:
  • Atorvastatin 40mg daily
  • Aspirin 81mg daily
  • Fish oil 1000mg daily
• Risk Assessment:
  • ASCVD 10-year risk: 8.5%
  • CK: 150 U/L (normal)
  • ALT: 25 U/L
  • AST: 22 U/L

Assessment

1. Hyperlipidemia
   • Above LDL goal
   • Moderate ASCVD risk
   • Statin tolerant
2. Lifestyle Modifications
   • Good diet adherence
   • Regular exercise
   • Weight management needed

Plan

1. Interventions:

   • Lipid therapy optimization
   • Risk factor review
   • Duration: 30 minutes
   • CPT Code: 99212

2. Medication Adjustments:

   • Increase atorvastatin to 80mg daily
   • Continue aspirin and fish oil
   • Monitor liver function
   • Track muscle symptoms

3. Patient Education:

   • Diet reinforcement
   • Exercise encouragement
   • Medication timing
   • Side effect monitoring

4. Follow-up:

   • Schedule 6-week follow-up
   • Repeat lipid panel
   • Monitor adherence/tolerance

9. Psychiatric Medication Review

Description

The patient presents for psychiatric medication management and monitoring in the pharmacy mental health clinic.

SOAP Note

Patient Name: Jennifer Williams

Date of Visit: 09/09/2024

Subjective

Jennifer Williams, a 35-year-old female with major depressive disorder and generalized anxiety disorder, presents for medication review. Reports improved mood but persistent anxiety symptoms. Sleep improved to 6-7 hours nightly. Attending weekly counseling. Reports good medication adherence but concerned about weight gain.

Objective

• Vital Signs:
  • BP: 122/74 mmHg
  • HR: 78 bpm
  • RR: 16/min
  • Weight: 75 kg (+3 kg in 3 months)
• Mental Status:
  • Alert and oriented x3
  • Appropriate affect
  • Normal speech
  • No suicidal ideation
• Assessment Scores:
  • PHQ-9: 8 (mild depression)
  • GAD-7: 12 (moderate anxiety)
  • AIMS: No abnormal movements
• Current Medications:
  • Sertraline 150mg daily
  • Buspirone 15mg BID
  • Trazodone 50mg qhs prn

Assessment

1. Major Depressive Disorder
   • Improved symptoms
   • Medication responsive
   • Weight gain concern
2. Generalized Anxiety Disorder
   • Persistent symptoms
   • Partial response
   • Ongoing stressors

Plan

1. Interventions:

   • Medication optimization
   • Side effect management
   • Duration: 45 minutes
   • CPT Code: 99214

2. Medication Adjustments:

   • Increase buspirone to 20mg BID
   • Continue sertraline unchanged
   • Continue trazodone prn
   • Monitor weight changes

3. Patient Education:

   • Lifestyle modifications
   • Stress management
   • Sleep hygiene
   • Diet/exercise counseling

4. Follow-up:

   • Schedule 4-week follow-up
   • Continue counseling
   • Monitor symptom changes

10. Antimicrobial Stewardship

Description

The patient presents for antimicrobial therapy monitoring and optimization in the pharmacy infectious disease clinic.

SOAP Note

Patient Name: William Chen

Date of Visit: 09/10/2024

Subjective

William Chen, a 48-year-old male, presents for follow-up of complicated UTI treatment. Currently on day 5 of 14-day course. Reports improved symptoms with no fever or flank pain. Denies adverse effects. Completing full course as prescribed. No new symptoms reported.

Objective

• Vital Signs:
  • BP: 118/72 mmHg
  • HR: 72 bpm
  • RR: 16/min
  • Temp: 37.0°C
• Laboratory Data:
  • WBC: 8.2 K/μL
  • SCr: 1.0 mg/dL
  • eGFR: 85 mL/min
  • Urinalysis: Improving
• Culture Results:
  • Organism: E. coli
  • Susceptible to current therapy
  • No resistance patterns
• Current Medications:
  • Cefpodoxime 200mg BID
  • Probiotics daily
  • Tylenol prn

Assessment

1. Complicated UTI
   • Improving on therapy
   • Appropriate coverage
   • Good tolerance
2. Antimicrobial Use
   • Appropriate duration
   • No adjustments needed
   • No adverse effects

Plan

1. Interventions:

   • Treatment monitoring
   • Culture review
   • Duration: 30 minutes
   • CPT Code: 99212

2. Medication Management:

   • Continue current antibiotic
   • Complete 14-day course
   • Monitor for completion
   • Review follow-up culture

3. Patient Education:

   • Completion importance
   • Hydration emphasis
   • Prevention strategies
   • Warning signs review

4. Follow-up:

   • Schedule post-treatment visit
   • Obtain follow-up cultures
   • Monitor resolution