From the Guidelines
A SOAP template for ambulatory care should include four key sections: Subjective, Objective, Assessment, and Plan, with a focus on comprehensive documentation and clear communication between healthcare providers. When creating a SOAP note for ambulatory care, consider the following key elements:
- In the Subjective section, document the patient's chief complaint, history of present illness, past medical history, medications, allergies, and social history.
- The Objective section should include vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation), physical examination findings, and relevant laboratory or diagnostic test results, such as those obtained from ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.
- For the Assessment section, list the patient's diagnoses in order of importance, including both acute and chronic conditions, with appropriate ICD-10 codes, and consider the use of ASCVD risk estimation to guide BP threshold for drug therapy as outlined in Section 8.1.2 of the guideline 1.
- The Plan section should detail the treatment approach for each diagnosis, including specific medications with names, dosages, routes, and durations, ordered tests with rationale, patient education provided, referrals made, and follow-up instructions, taking into account the need to introduce lifestyle interventions, identify and discuss treatment goals, and align treatment options with comorbidities as recommended in the guideline 1. The SOAP format is particularly valuable in ambulatory care as it creates a logical flow of information that supports clinical decision-making and continuity of care across multiple visits, and can be used in conjunction with team-based care and telehealth to improve patient outcomes 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
SOAP Template for Ambulatory Care
There are no research papers to assist in answering this question as the provided studies are related to the pharmacodynamic and pharmacokinetic properties of lisinopril, its therapeutic use in hypertension and congestive heart failure, and its comparison with other antihypertensive drugs.
- The studies 2, 3, 4, 5, 6 focus on the efficacy and safety of lisinopril in treating hypertension, but do not provide information on creating a SOAP (Subjective, Objective, Assessment, Plan) template for ambulatory care.
- A SOAP template is a standardized method of documenting patient information, but its creation and content are not addressed in the provided studies.
- The studies primarily discuss the clinical use of lisinopril, its mechanisms of action, and its comparison with other antihypertensive agents, but do not provide guidance on developing a SOAP template for ambulatory care.