Abstract

Subjective, Objective Assessment and Plan (SOAP) notes have a major significance in healthcare; but there is no standard format for documentation. The objective of this study is to develop and validate advanced SOAP (A-SOAP) 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 one-way analysis of variance were carried out to measure the difference in scores and its significance. The scores of A-SOAP were more noteworthy (57.94 ± 15.86) in comparison to SOAP 1 (14.49 ± 12.95) at p < 0.001. The distribution of scores was also significantly different among participants of various academic years. The efficiency in problem identification and documentation had improved with A-SOAP.

Key words: SOAP note, pharmacy, documentation, validation, experiential education, medical record