CHPPC Module 11, Section 3: Documentation: The Art of the Clinical Note
MODULE 11: PROFESSIONAL PRACTICE & COMMUNICATION

Section 3: Documentation: The Art of the Clinical Note

You have mastered the skills of verbal communication with nurses and physicians. Now, we turn to the most permanent and scrutinized form of professional communication: the written clinical note. In the hospital, the mantra is absolute: “If it wasn’t documented, it wasn’t done.” Your clinical interventions, recommendations, and thought processes have no value if they are not recorded in the patient’s legal medical record. This section will teach you how to translate your clinical judgment into effective, concise, and defensible progress notes that become a cornerstone of the patient’s care narrative.

3.1 The EHR as a Legal and Clinical Record

Why your written words are as important as your clinical actions.

In retail pharmacy, your documentation is extensive but often exists in discrete, task-oriented silos: the prescription hardcopy with your verification notes, the log of a verbal clarification, the record of a controlled substance fill. The Electronic Health Record (EHR) in a hospital is fundamentally different. It is a single, unified, longitudinal story of the patient’s entire hospital stay. Your note is not a separate pharmacy record; it is a permanent chapter in that story, read by every member of the care team, by coders and billers, by quality assurance auditors, and potentially, by lawyers in a courtroom years later.

Retail Pharmacist Analogy: The Detailed Tamper-Proof Prescription Pad Annotation

Imagine you receive a questionable prescription for a high dose of oxycodone. You perform your due diligence: you call the prescriber, speak to them directly, confirm the dose, discuss the patient’s diagnosis, and document the prescriber’s rationale. You don’t just jot “V.V.” on the script. You write a detailed, unalterable note directly on the hardcopy: “10/04/25 @ 14:30: Spoke with Dr. Smith directly via phone. Confirmed dose of oxycodone 30mg QID is intentional for patient’s documented diagnosis of metastatic bone cancer with severe pain. Dr. Smith states patient is opioid-tolerant and this is an escalation of previous therapy. – C. Pharmacist, RPh”.

This meticulous, defensible note is the direct ancestor of a hospital pharmacist’s progress note. You have captured your action (the call), your assessment (the dose is high but clinically justified), and the outcome (confirmation). Now, instead of writing it on a paper script that gets filed away, you will type it into a shared electronic record where it informs the next shift’s pharmacist, the patient’s nurse, and the attending physician of your exact thought process and contribution to the patient’s care plan.

The Multiple Audiences of Your Clinical Note

When you write a note, you must consider the multiple professionals who will read it. Each audience has a different need, and a well-written note serves them all simultaneously.

Audience What They Need from Your Note
Physicians (Attendings, Residents) A clear assessment of the medication-related problem and a specific, actionable recommendation. They need the “bottom line” quickly.
Nurses Awareness of changes to the medication plan, monitoring parameters to watch for, and the rationale behind a medication choice they will be administering.
Other Pharmacists (Next Shift) A clear handover of your thought process. Why did you recommend holding the vancomycin? What is the plan for re-checking the INR? Your note ensures continuity of pharmaceutical care.
Case Managers / Social Workers Information about high-cost medications or complex regimens that may impact the patient’s discharge plan and ability to obtain medications post-hospitalization.
Coders and Billers Documentation of clinical activities that may support specific billing codes for pharmacy services (e.g., pharmacokinetics, anticoagulation management).
Quality/Safety Officers & Legal Teams A defensible, factual record of your actions and clinical judgment in the event of an adverse drug event or a legal challenge. Your note demonstrates you were practicing within the standard of care.

3.2 The Anatomy of a Pharmacist’s Progress Note: The SOAP Method

A universal framework for structuring your clinical thoughts and recommendations.

While various documentation formats exist, the SOAP note is the most widely recognized and utilized framework for clinical documentation across all health professions. Mastering this structure allows you to organize your findings logically and present them in a way that is immediately understandable to physicians, nurses, and other providers. Each section serves a distinct purpose, building a case that leads from raw data to your final, expert recommendation.

Deconstructing the SOAP Note

S Subjective

This section captures information that cannot be measured objectively. It is what the patient, family, or nurse tells you. For pharmacists, this is often brief but can provide critical context.

  • Patient-reported symptoms: “Patient reports nausea after taking her morning medications.”
  • Pain level: “Patient reports pain is 5/10, improved from 8/10 yesterday.”
  • Information from nursing: “Nurse reports patient has had no bowel movement in 3 days.”
  • Adherence information: “Patient states she has not been taking her home lisinopril due to a persistent cough.”

O Objective

This section is for hard data only. It contains measurable facts from the EHR. Avoid interpretation here; just state the facts.

  • Vitals: BP 145/90, HR 88, T 37.8 C, RR 18, SpO2 96% on RA.
  • Lab Results: Na 138, K 3.1, SCr 1.9 (baseline 0.9), WBC 14.2, Hgb 9.5. INR 2.5.
  • Drug Levels: Vancomycin trough 23.2 mcg/mL (Goal 15-20).
  • Medication Administration Record (MAR): “Patient received hydromorphone 0.5mg IV at 0200, 0600. Last dose of warfarin 5mg given yesterday at 1700.”
  • Imaging/Microbiology: “Blood cultures from 10/3 showing MSSA. Chest X-ray shows LLL infiltrate.”

A Assessment

This is the most important part of your note. It is where you demonstrate your clinical value.

Here, you synthesize the Subjective and Objective information to identify and evaluate a medication-related problem. You are connecting the dots. It is your professional analysis of the situation.

  • Problem Identification: “Supratherapeutic vancomycin trough likely secondary to worsening acute kidney injury.”
  • Therapeutic Goal Assessment: “Therapeutic INR of 2.5 for treatment of DVT.”
  • Risk/Benefit Analysis: “Patient’s opioid-induced constipation is contributing to her abdominal pain and nausea.”
  • Efficacy Evaluation: “Despite three days of broad-spectrum antibiotics, patient remains febrile with leukocytosis, suggesting current therapy may be inadequate pending final culture sensitivities.”

P Plan

Based on your Assessment, what are you going to do or recommend? The plan must be specific, actionable, and numbered if there are multiple parts.

  • Specific Recommendations: “1. Recommend holding next dose of vancomycin. 2. Recommend re-checking trough level prior to the subsequent dose. 3. Will recalculate maintenance dose based on repeat level.”
  • Actions Taken: “1. Paged Dr. Smith with above recommendation; verbal order received and entered.”
  • Monitoring Parameters: “2. Continue to monitor SCr daily. Monitor for signs of nephrotoxicity.”
  • Patient Education: “3. Will educate patient on use of PRN senna/docusate for constipation.”

3.3 Writing Effective and Defensible Notes

Principles for crafting notes that are clear, concise, and professional.

A well-structured note is only half the battle. The language you use is equally important. Your writing should be professional, objective, and unambiguous. Every word should serve a purpose. In the busy hospital environment, no one has time to read a novel; they need to understand your assessment and plan in seconds.

Golden Rules of Clinical Documentation

  • Be Objective, Not Judgmental: Document the facts, not your personal opinions. Avoid terms like “non-compliant,” “difficult,” or “drug-seeking.” Instead, describe the behavior.
  • Write in the Third Person: Notes are about the patient. Instead of “I think,” write “The patient’s symptoms are likely due to…” or “Pharmacist recommends…”
  • Avoid Ambiguous Abbreviations: While some abbreviations are standard (e.g., PO, IV, QID), avoid unapproved or easily misinterpreted ones. When in doubt, write it out. The ISMP has a list of error-prone abbreviations to avoid.
  • Document Communications: Always “close the loop.” If you make a recommendation, document who you spoke to, what their response was, and what action was taken. This is critical for both continuity and liability.
  • Be Timely: Document your interventions as close to the time they occur as possible. A note written 3 days after the fact is far less credible than one written in real-time.
  • Proofread Your Work: Spelling and grammar matter. A sloppy note can undermine your credibility. Take 15 seconds to re-read your note before you sign it.

Good Note vs. Bad Note: A Comparative Analysis

Let’s examine two notes documenting the same scenario to highlight the difference between ineffective and effective documentation.

Scenario: A pharmacist is called by a nurse because a patient on warfarin with a goal INR of 2-3 has a critical INR of 9.2.

Bad Note Example

INR is high. Held warfarin. Notified MD.

Why this is ineffective:

  • Lacks critical data (What was the INR? What was the warfarin dose?).
  • Vague (“Notified MD” – Who? When? What was their response?).
  • No assessment of why the INR is high.
  • No plan for resumption or follow-up.
  • Offers no value to the next person reading the chart.

Good Note Example (SOAP Format)

S: Per nursing, patient has no signs/symptoms of active bleeding (e.g., no epistaxis, hematuria, or new bruising noted).

O: Patient on warfarin 5mg PO daily for atrial fibrillation. Today’s INR is 9.2 (goal 2-3). Patient also received 3 doses of Bactrim for presumed UTI over the past 48 hours. SCr is stable at 1.0.

A: Critically elevated, supratherapeutic INR likely due to a significant drug-drug interaction between warfarin and sulfamethoxazole-trimethoprim. Patient is at high risk for bleeding.

P:
1. Recommend HOLD warfarin tonight (10/4) and tomorrow (10/5).
2. Recommend against use of Vitamin K at this time as patient is not actively bleeding, per AHA/CHEST guidelines.
3. Recommend re-checking INR in AM tomorrow (10/5).
4. Paged Dr. Jones with above assessment and recommendations. Verbal order received to hold warfarin x 2 doses and re-check morning INR. Will continue to follow.

3.4 Real-World Scenarios: Documenting Common Interventions

Putting theory into practice with case-based examples.

The best way to master the art of the clinical note is to see it in action. In this section, we will walk through several common inpatient scenarios and provide a model SOAP note for each one. Study these examples to understand how to apply the principles we’ve discussed to your daily practice.

Scenario 1: Vancomycin Dosing and Monitoring

Case: 68-year-old male with MRSA bacteremia. Weight 80kg, SCr 1.8. You are asked to dose vancomycin. After 3 doses, you check a trough.

Model Pharmacokinetics Note:
Pharmacokinetics - Vancomycin

S: Patient is clinically improving, afebrile per nursing.

O:
Weight: 80kg, Age: 68, SCr: 1.8 mg/dL (est. CrCl ~40 mL/min).
Indication: MRSA Bacteremia.
Initial Dose: 1500mg IV Q12H (20 mg/kg loading dose, then ~15 mg/kg/dose).
Vancomycin trough level drawn prior to 4th dose: 18.2 mcg/mL.

A:
The current vancomycin trough of 18.2 mcg/mL is therapeutic for MRSA bacteremia (goal 15-20 mcg/mL). The current maintenance regimen of 1500mg IV Q12H is appropriate to maintain this target level. The patient's renal function is stable.

P:
1. Continue current vancomycin dose of 1500mg IV Q12H.
2. Recommend re-checking trough level in 3-5 days or sooner if renal function changes.
3. Continue to monitor SCr daily, and for signs of nephrotoxicity or ototoxicity.
4. Communicated plan to primary team during morning rounds.

Scenario 2: IV to PO Conversion

Case: 52-year-old female admitted for community-acquired pneumonia, started on IV ceftriaxone and azithromycin. On hospital day 3, she is doing well.

Model IV to PO Note:
IV to PO Conversion Recommendation

S: Patient reports feeling "much better" and is asking when she can go home.

O:
Indication: Community-Acquired Pneumonia.
Current therapy: Ceftriaxone 1g IV daily, Azithromycin 500mg IV daily.
Hospital Day #3.
Vitals: Tmax 37.5 C in past 24h. HR 85, BP 120/75.
Labs: WBC trended down from 16.1 to 10.5.
Diet: Tolerating regular diet, taking other PO meds.

A:
Patient is clinically stable and meets institutional criteria for conversion from IV to PO antibiotic therapy:
1. Temperature < 38 C for >24 hours.
2. WBC trending down.
3. Functioning GI tract and tolerating PO intake.
Oral azithromycin and cefpodoxime offer excellent bioavailability and appropriate coverage to complete therapy.

P:
1. Recommend discontinuing IV ceftriaxone and IV azithromycin.
2. Recommend initiating:
   a. Azithromycin 500mg PO daily to complete 5-day total course.
   b. Cefpodoxime 200mg PO BID to complete 7-day total course.
3. Paged Dr. Miller with recommendations; verbal order received and entered. This change will facilitate earlier discharge.

Scenario 3: Pain Management Optimization

Case: 80-year-old post-op hip fracture patient complaining of pain. Currently ordered for morphine 2mg IV Q4H PRN. MAR shows she has required 5 doses in 24 hours and still reports 7/10 pain.

Model Pain Management Note:
Pain Management Recommendation

S: Patient reports constant, dull right hip pain, rated 7/10. States the "shots for pain help, but only for a little while."

O:
Patient is post-op day #2 s/p ORIF of right hip.
Current analgesic: Morphine 2mg IV Q4H PRN.
MAR indicates patient has received 5 doses in the last 24 hours (10mg total).
Patient is also on senna-docusate daily.

A:
Patient's post-operative pain is inadequately controlled with the current PRN-only intravenous opioid regimen. The frequent need for PRN doses suggests a scheduled, long-acting agent would provide better baseline pain control and reduce reliance on breakthrough medication. A multi-modal approach incorporating a scheduled non-opioid would also be beneficial.

P:
1. Recommend initiating scheduled, around-the-clock analgesia to provide better baseline pain control:
a. Acetaminophen 650mg PO every 6 hours scheduled.
b. Oxycodone 5mg PO every 6 hours scheduled.
2. Recommend adjusting breakthrough medication to oxycodone 5mg PO every 4 hours PRN for pain rated > 6/10.
3. Continue to monitor for efficacy and side effects (e.g., sedation, constipation). Ensure bowel regimen remains effective.
4. Discussed above multi-modal pain management strategy with Dr. Chen; verbal orders received and entered.