Assessment of SOAP note evaluation tools in colleges and schools of pharmacy

Abstract

Introduction: To describe current methods used to assess SOAP notes in colleges and schools of pharmacy.

Methods: Members of the American Association of Colleges of Pharmacy Laboratory Instructors Special Interest Group were invited to share assessment tools for SOAP notes. Content of submissions was evaluated to characterize overall qualities and how the tools assessed subjective, objective, assessment, and plan information.

Results: Thirty-nine assessment tools from 25 schools were evaluated. Twenty-nine (74%) of the tools were rubrics and ten (26%) were checklists. All rubrics included analytic scoring elements, while two (7%) were mixed with holistic and analytic scoring elements. A majority of the rubrics (35%) used a four-item rating scale. Substantial variability existed in how tools evaluated subjective and objective sections. All tools included problem identification in the assessment section. Other assessment items included goals (82%) and rationale (69%). Seventy-seven percent assessed drug therapy; however, only 33% assessed non-drug therapy. Other plan items included education (59%) and follow-up (90%).

Discussion and conclusions: There is a great deal of variation in the specific elements used to evaluate SOAP notes in colleges and schools of pharmacy. Improved consistency in assessment methods to evaluate SOAP notes may better prepare students to produce standardized documentation when entering practice.

Keywords: Assessment; Documentation; SOAP notes.