In this episode, I’ll discuss the format I use to write a pharmacy progress note.
First I’ll talk about the format I do not use, and that is the SOAP note format.
SOAP notes are usually “overkill” and result in a lengthy note with lots of copy- pasting of information that did not originate from my expertise (like a physical exam or review of systems).
I find that SOAP notes are good for two things:
1. For physicians to document in a problem-based format
2. For pharmacy professors to see how much material their students have learned
I use an alternative to SOAP to structure my progress notes called TITRS:
I find this format helps me be succinct, yet still communicate the information I feel is necessary in my notes. Here is how I write a pharmacy progress note using TITRS:
The title answers the questions: Who am I and why am I here to help this patient?
The introduction answers the questions: Who is the patient and why are they in the hospital / in need of a pharmacy consult?
The text is the subjective & objective information necessary to support the recommendations.
Recommendations should be clear, complete, and follow logically from the supportive text.
The signature should include name, title, and phone number.
You can get an example progress note that uses the TITRS format and a 2-page guide on how to write a progress note in my free download area at pharmacyjoe.com/free. It’s download # 14 on the list. And for more detailed information on writing progress notes, using sticky notes for interventions (sometimes) and documenting clinical services outside of the medical record I have a new Masterclass training in the Hospital Pharmacy Academy. Go to pharmacyjoe.com/academy for immediate access.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.