Recording a consultation

Pharmacists need to complete a clinical summary of any consultation as part of the patient record. Most GP computer systems provide a framework for systematically recording clinical findings and decisions made during the consultation. Pharmacists may not yet have access to such a structured approach and instead have only a single free text box to fill in.

It is important to follow a structured approach to ensure that important information has been captured in a way that fits with other entries in a patient’s primary care clinical record. The GP, when looking at the record, needs to be able to rapidly glean the key information.

A further reason is that, in the case of any challenge to a pharmacist’s clinical decision-making, it can help justify any actions taken. One approach commonly used in recording information is the acronym SOAP. This is a consultation structure based on the following:

• Subjective
• Objective
• Assessment
• Plan.

It might sound simplistic, but this model has been used for many years and has stood the test of time. It is a recording structure built into many GP clinical systems:

• Subjective: This should include a description of how the patient is feeling in their own words. Pharmacists should document the patient’s responses accurately and use quotation marks if directly quoting something they have said
• Objective: This must include observations that are objective in nature, which are things a pharmacist can measure, see, hear, feel or smell. This includes the appearance of the patient (pale or sweaty, for example), clinical observations and investigation results (such as temperature, pulse rate or blood pressure) where relevant
• Assessment: This is where important details are documented along with a diagnosis (or differential diagnosis) based on the information gathered. This could be an impression of the likely cause of the problem. If the diagnosis is fairly clear, the severity of the problem can be recorded, and whether it is improving or deteriorating
• Plan: The final part of this approach is the plan, which is where any issues to be addressed or investigated further are documented. This should include the reasons why the investigations or referrals are needed, or any treatment that has been provided (such as antibiotics via a Pharmacy First PGD).

When the patient is to be reviewed next, along with any advice given, should also be recorded. This can include information given to the patient, including printed materials. Most importantly, any safety-netting advice should be recorded