GAUTHAM COLLEGE OF PHARMACY

The final component of the note is used to outline the plan for future sessions. The therapist should report on what the patient's Home exercise programme (HEP) will consist of, as well as the steps to take in order to reach the functional goals. Changes to the intervention strategy are documented in this section.

 

The plan is what the health care provider will do to treat the patient's concerns - such as ordering further labs, radiological work up, referrals given, procedures performed, medications given and education provided. The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters. This should address each item of the differential diagnosis. For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and urgency for therapy. A note of what was discussed or advised with the patient as well as timings for further review or follow-up are generally included.

 

The plan (P) may include ordering additional diagnostic tests or initiating, revising, or discontinuing treatment. If the plan includes changes in pharmacotherapy, the rationale for the specific changes recommended should be described. The drug, dose, dosage form, schedule, route of administration, and duration of therapy should be included. The plan should be directed toward achieving a specific, measurable goal or endpoint, which should be clearly stated in the note. The plan should also outline the efficacy and toxicity parameters that will be used to determine whether the desired therapeutic outcome is being achieved and to detect or prevent drug-related adverse events. Ideally, information about the therapy that should be communicated to the patient should also be included in the plan. The plan should be reviewed and referred to in the note as often as necessary.

 

Common errors:

• The upcoming plan is not indicated.

• Vague description of the plan e.g. "Continue treatment"