1

藥事執業技能：藥物相關問題之解決Pharmacy Practice Skills: Drug-Related

Problems Solving

　　　 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　

2

課程目的• 了解 systematic clinical drug monitoring 的重要性與目的

• 說明 SOAPing format 之組成及擷取藥事服務所需資訊

• 了解 patient case presentation 之結構及順序• 學習以 SOAPing format 建立完整的合理用藥評估

• 藉案例學習，引導學生與指導老師充分互動 - 重視討論的過程，而非結果

3

Systematic Clinical Drug Monitoring的重要性

• The responsibility of a pharmacist to provide services in a consistent and complete manner

• The complexity of a patient’s health problems

• The comprehensible communication among health care professionals

4

The Purposes of Systematic Clinical Drug Monitoring

• Determine that all of a patient’s drug therapy is the most appropriate, most effective, safest, and most convenient available.

• Identify any drug therapy problems (DTPs; DRPs) and the goal of therapy.

• Identify any drug therapy problems (DTPs) the patient is at risk of developing in the future that is to say, any drug therapy problems the pharmacist must help the patient to prevent in the future

5

Pharmaceutical Care Process

6

Problem-Oriented Approach

• In 1964, Lawrence E Weed published the problem-oriented approach to medical records, patient care, and medical education.

• A systematic, disciplined approach to each patient is used

• No important therapeutic considerations are missed

7

Problem-Oriented Approach

• Two main components– Complete problem list

• Physical• Psychological• Social/financial

– SOAP notes• Logical thinking process•連結理論和臨床 , 並應用在醫療照顧• One visit one SOAP

8

POMRProblem Oriented Medical Record

• Dr. Lawrence Weed 提出將病歷制式化的構想

POMR= Problem List ( 第 x 項 ) + 各個 SOAP

– Problem 1+ SOAP 1– Problem 2+ SOAP 2 – … …

• Modified SOAP S O A (Problem 1, 2, …) P (Problem 1, 2, …)

9

教學大綱• 課程目標• 病歷之基本組成

– Patient Case Presentation

• From database to plan– 1. From data base to assessment (SOAP notes)– 2. Assessment– 3. From assessment to plan (Implentation)

• SOAPing format– 案例說明

• Daily SOAP note• Oral case presentation

10

教學內容重點

11

實際指導學生實習 - 案例討論• 課程準備

– 安排課程表 - 學習過程– 準備內容教材 ( 挑選主題 , 範例 , 實例 , workbook,

pharmacotherapy 之參考依據 )• Disease Management Case Demo (ASHP’s PharmPrep 2001)• Terry L. Schwinghammer pharmacotherapy Casebook 6th Ed.

• 課程分配– 需多堂課 (10 幾個小時 )– 漸進地介紹 , 才能完成

• 1. 上課解說 2 小時• 2. 範例說明 1 小時• 3. 學生實例演練 SOAPing format 及討論 (2 小時 / 次 , 共 5-6 次 )

12

病歷之基本組成

13

病歷之基本組成

• 首頁• 門診病歷• 住院病歷• 急診病歷

14

住院病歷• 病歷摘要 (Discharge summary)• 醫囑單 ( 一般 / 特殊 -TPN 及 C/T)• TPR sheet• Admission note ( 內科及外科 / 一般或各專科病歷用紙 )• Progress note (SOAP format)• 會診記錄• 治療申請單 (X-ray, Cath, RT)• 檢驗報告 (Lab data)• 監測觀察記錄單 (GCS, APACHE II scale)• 輸入輸出記錄表 / 膀胱訓練記錄表• 手術記錄• 給藥記錄• 護理評估表 / 護理記錄• 出院準備服務 個案篩選表 / 收案病患記錄表

15

Medication Administration Record(MAR)

• Routine or maitenance– Antibiotics, anticonvulsants

• P.R.N.– Usually are listed at the end of the MAR– Fever (if >38.5 )℃– Pain medication– Antiemetics– Sedative-hypnotic agents

• Stat (Statim, immediately)– Administered once and not repeated unless recorded– Given as soon as possible– Prescribed in life-threatening or emergency situations

• One time order– Given as soon as convenient and sometimes can be scheduled ahead of time– C/T

16

住院日誌 Progress Note • 目的

提醒每天病人發生了什麼事以及醫師目前的想法• 精神 - 忠實記錄 , 簡短 ( 縮寫 ), 清晰易讀 , 遵守常用習慣 • 重要性

– 對病患病程的演進，客觀的變化，醫師的判斷，臨床的因應做一個重要的記錄

– 對病患而言，這是他的”傳記”，是他一生最重要的記錄

– 對醫師而言，這是他訓練過程的”事證”，對自己的想法與做法留下記錄 ; 也是醫師間溝通的工具

– 對醫療而言，是醫療的重點記錄，是疾病處理的基本依據，是繼續醫療的重要參考

– 對醫學而言，是人類醫學的重要資產，是醫學進步重要文獻

• 格式 -SOAP format

17

常用縮寫

• 一般身體評估 ( 身體診察 )

• 疾病診斷• 藥品及其用法• 檢查名稱

18

推薦讀物 ( 入門 )• 醫護專用縮寫辭典 ( 杜武志 主編 )

– 取材範圍廣泛• 醫 , 牙 , 藥 , 護 , 檢驗 , 管理• 疾病診斷 , 理學檢查 , 名稱 , 病歷用語

• 台大內科住院醫師醫療手冊 ( 楊汾池 總編 )– 一般內科訓練 (primary care training)– 綜論 ( 醫療實務要點 , 各病房特殊檢查及術後照顧 )– 各論 (CV, GI, Nephro, Chest, Endo, Neuro, Rheuma, ID, Hema, Oncology)

• The Washington Manual of Medical Therapeutics 31ed.• Clinical skills for pharmacists, A patient-focused approach.

2nd Ed. Karen J. Tietze, Mosby

19

Patient Case Presentation

The accepted tool for documenting and communicating

patient information (suggested by Tietze, K.J.)

20

Components of the Patient Case Presentation

• General information• Chief complaint (CC)• History of present illness

(HPI)• Past medical history (PMH)

Medication history (MedHx)• Family history (FH)• Social history (SH) • Review of systems (ROS)• Physical examination (PE)

• Pertinent positive and negative laboratory and diagnostic test results (Labs)

• P’t problem list and initial plans

• P’t progress• Discharge data

– Final diagnosis

– Discharge medications

• Plans for follow-up

21

Suggested Sequence for Presentation of Information

General information (Gen) ↓Chief complaint (CC) ↓History of present illness (HPI) ↓Past medical history (PMH) ↓Social history (SH) ↓Family history (FH) ↓Medication history (MedHx) ↓

↓Review of systems (ROS) ↓Physical examination (PE) ↓Laboratory and diagnostic test

results (Lab) ↓Problem list and initial plans (SOAP format) ↓P’t progress to date (SOAP format)

22

From database to plan

Steps of Systematic Clinical Drug

Monitoring(suggested by Shao C, Chiang, Pharm.D., R.Ph.)

23

Problem Conversion

Medical problems (Dx)

Medication problems

(Drug therapy problems )

24

From Database to Plan

• 1.From data base to assessment– SOAP notes

• 2.Assessment• 3.From assessment to plan (Implentation)

– Therapeutics planning-pharmacist• Diagnostic• Therapeutic (Prescription)• Educational (p’t)

– Monitoring

25

1.From data base to assessment (SOAP notes)

At admission (new p’t)

26

SOAPingProblem list

numberedacuity/priorityResolved / inactive

Database

CCHPIPMHFHSHMed Hx Compliance AllergiesROSPELab testsX-rayScansProcedureSOAP notes

SOAP notes

Implementation of plan

diagnostic

therapeutic

educational (p’t)

Follow-up of progress

27

2. Assessment

At admission (new p’t)

28

Interpret the Findings in Terms of the Probable Process

• Pathological process

– Congenital / Inflammatory

– Immunological / Neoplastic

– Metabolic / Nutritional

– Degenerative / Vascular

– Traumatic / Toxic

• Pathophysiological

• Psychopathophysiological

• Drug-related

29

Make One or More Hypotheses about the Nature of the Patient’s Problem

• Select the most specific and central findings around which to construct your hypothesis.

• Match your findings against all the conditions you know that can produce them.

• Eliminate the diagnostic possibilities that fail to explain the findings.

• Weigh the competing possibilities and select the most likely diagnosis from among the conditions that might be responsible for the patient’s findings

• Give special attention to potentially life-threatening and treatable conditions

30

3.From assessment to plan (Implentation)

Therapeutics planning

At admission (new p’t)

31

Components of Therapeutics Planning

* Regimens- initial & alternative

32

The Planning Process

• Problem identification– Identification of subjective and objective parameters– Grouping of related parameters– Assessment of the parameters and determination of specific

p’t problems• Problem prioritization: Identify active and acute problems• Selection of specific therapeutic regimens

– Creation of a list of therapeutic options– Elimination of drugs from the list based on p’t-specific and

external factors– Selection of dosage, route, and duration of therapy– Identification of alternative therapeutic regimens

• Creation of a monitoring plan– Monitoring and modification of the regimens as necessary

33

Anxiety

Bloating

Blood-tinged sputum

Blurred vision

Breast tenderness

Chills

Cold intolerance

Confusion

Constipation

Cramps

Decreased appetite

Depression

Diarrhea

Difficulty concentrating

Dry skin

Dysuria

Fatigue

Flatulence

Headache

Heartburn

Heat intolerance

Impotence

Indigestion

Insomnia

Itching

Joint pain

Loss of appetite

Loss of libido

Muscle aches

Muscle weakness

Nasal congestion

Nasal itching

Nausea

Nervousness

Numbness

Pain

Palpitations

Pounding pulse

Rash

Seizures

Shortness of breath

Slurred speech

Sneezing

Sore throat

Syncope

Thirst

Tingling

Tinnitus

Tremor

Vertigo

Weakness

Wheezing

Common Subjective Parameters

34

BH and BW

Vital signs

BT, BP, HR, RR

Blood chemistries

Na, K , Cl, CO2, Glu, Scr, AST, ALT, Bil, Ca, Mg, CHL, TG, Alk-P, LDH, UA, BUN

Blood gases

pH, Pco2, Pco2, HCO3-

Blood protein

Total protein, albumin, complements, immunoglobulins

Hematolog

Hb, Hct, MCV, MCH, MCHC, RBC, WBC DC

Urinalysis

Sp. gr, cellular content, protein

Cultures and sensitivites

Blood, urine, sputum, tissue

Serum blood concentrations

Specific organ system tests

PEFR, FEV1, FVC , FEV1/FVC, EF, T3, T4, TSH, Clcr

Miscellaneous

U/O, abd girth, no. of loose stools/day, I/O

Common Objective Parameters

35

Factors to Consider when Selecting a Specific Therapeutic Regimen

• Patient-specific factors– What regimens have effectively managed the problem in the

past？– What regimens have not effectively managed the problem in the

past？– How might other patient problems influence the proposed

regimen？– How might the proposed regimen influence other patient

problems？• External factors

– Current “state of the art” therapeutics– Cost of the proposed therapv– Formulary limitations

36

Guidelines for Altering Initial Drug Therapy• If the regimen is ineffective, change the drug if the following are

true– The patient received an adequate trial of the drug– The patient received an adequate dosage of the drug– The patient is compliant

• If the regimen is associated with life-threatening side effects, discontinue the drug

• If the patient is not complying with regimen because of unacceptable side effects, discontinue the drug

• If the patient has non-life-threatening side effects and is willing to continue the drug,– minimize the side effects by doing the following:

• Adjust the dosage of the drug• Change the timing of the dose

37

3.From assessment to plan (Implentation)

Monitoring

At admission (new p’t)

38

Patient-Focused Care Cycle A Never-Ending Cycle

Data acquisition and assessment

Problem identification and prioritization

Therapeutic planning

Patient monitoring

39

The Process of Monitoring Therapeutic Regimens

1. Set therapeutic goals

2. Determine patient- and drug-specific monitoring parameters

3. Integrate the monitoring plan

4. Obtain data

5. Assess the response to therapy

6. Alter the therapeutic regimen if necessary

7. Repeat Step 1-6

40

Organization of Monitoring Parameters

(The Four-Square Method)Subjective-Therapeutic Subjective-Toxic

expected therapeutic outcome indicating therapeutic failure

or harm

Objective-Therapeutic Objective-Toxic

expected therapeutic outcome

indicating therapeutic failure

or harm

41

Steps of systematic clinical drug monitoring at inpatient setting

Hospital stay (old p’t)

42

Hospital Stay

• Daily SOAP note– Each problem has its own SOAP note.– The subjective and objective data should include

the values of drug monitoring parameters.– All problems should be assessed and planed,

unless the problem has been resolved

• Daily drug monitoring

43

Real Practice Setting

• With time and practice, the process of assessing patient therapy and prioritizing the need to make an intervention becomes second nature and does not require a concerted effort to mentally check off each step after it has been performed.

• Setting priority about which patients require more in-depth intervention.

44

SOAPing format

45

SOAPing Format

• SOAPing The process of identifying the subjective and objective data,

assessing the problem, and developing a specific therapeutic and monitoring plan

• A formal organizationl structure

• Steps– Creation of a list of related subjective parameters– Creation of a list of related objective parameters– Assessment and documentation of the problem– Documentation of the therapeutic plan for addressing the

problem

46

Thinking Process Tips

• Problem identification

• Desired outcome

• Therapeutic alternatives

• Optimal plan

• Outcome evaluation

• Patient education

47

Problem ListCurrent medical problems Goal of therapy Measurable endpoint

48

SOAPing FormatUSC School of Pharmacy Kathleen Besinque Pharm D, MS Ed.)

Subjective and Objective Assessment Plan

Problem

(subjective

and

objective)

Current

medication

Etiology (or risk

factors)

Evaluate need for therapy; evaluate

current therapy (Evidence need for

therapy evaluation)

Recommended drug

treatment, drug to

be revised, further

test

Goal and

monitoring

parameters (toxic

and therapeutic)

Patient

education

49

Current Drug-Therapy ProblemsSubjective and Objective

Problem(subjective and objective)

Current medication

S: CC:

Pertinent medical Hx:(HPI / PMH)

ROS:

SH:

FH:

Allergies:

ADR:

Drugs

OTCs

Herbal

O:

(PE /Labs)

50

Current Drug-Therapy ProblemsAssessment

Etiology

(or risk factors)

Evaluate need for therapy; evaluate current therapy (Evidence need for therapy evaluation)

Drug therapy problem 1

CPG1

Class of drugs

Drug therapy problem 2

CPG2

Class of drugs

Drug therapy problem 3

CGP3

Class of drugs

51

Current Drug-Therapy ProblemsPlan

Recommended drug treatment, drug to be revised, further test

Goal and monitoring parameters (toxic and therapeutic)

Patient education

Recommend 1

Item of drugs

Goal 1

Therapeutic

Toxic

Education 1

Recommend 2

Item of drugs

Goal 2

Therapeutic

Toxic

Education 2

Recommend 3

Item of drugs

Goal 3

Therapeutic

Toxic

Education 3

52

Problem Conversion

Medical problems (Dx)

Medication problems

(Drug therapy problems)

53

教學時遭遇的困難與處理

54

教學時遭遇的困難與處理 (1)• 藥師指導 clinical drug monitoring 及 case presentation 之技巧有差異– 參與醫院藥學實習指導師資認證訓練課程

• 閱讀病歷抓不到 (困難擷取 ) 藥事服務所需資訊– Medical problem (Dx) Medication problems

(Drug therapy problems)

– 病歷上少有藥師的記錄或看到 daily SOAP note

• 持續練習就能習慣• 如何釣魚需由作中去領悟

55

教學時遭遇的困難與處理 (2)• 教學過程多是由指導藥師來告訴答案

– 藥師在藥事服務介入的時間多於學生– 報告時間的壓力– 學生常是事到臨頭才要做– 學生難於確認那麼多 Drug therapy problems

• 臨床教學模式– 常是糾正學生的錯誤 , 解釋處理 Drug therapy problems的原則

– 已修過藥物治療學 / 臨床藥學課程者再實習• 病案報告非 concurrent case

– 藥師需作調劑工作– 藥師未全程參與病患照護– 難了解醫師對藥師意見的接受度及藥師建議的可行性

56

結論• Problem oriented drug monitoring

• 有清晰的邏輯思考• 可解決複雜的 Drug therapy problems

•本課程是建立思考邏輯•沒有絕對標準的答案•引導學生 / 藥師的指導藥師 -很重要

57

Case Example( 案例說明 )Hypertension

58

課程目標 (HTN)

• Establish goals for the treatment of HTN.

• Choose appropriate lifestyle modifications and anti-HTN based on patient-specific characteristis and concurrent disease states.

• Design appropriate monitoring plans for pts receiving anti-HTN therapy, including laboratory parameters and time intervals.

• Modify pharmacotherapeutic regimens for pts who experience adverse events or do not have adequate BP reduction on an initial regimen.

• Provide appropriate patient education for anti-HTN regimens.

59

Patient General Information (Gen)病患基本資料

Patient name: 王先生Chart no: xxxxxxxx

(Bed no: xxxx-x)

Address: 台南市信義路Age: 79 Height: 175 cm

Sex: M Marriage status: married

Weight: 95.4kg Allergies: NKDA

Date of admission (DOA) : yy mm dd

60

Chief Complaint (CC)病患主訴病情

• 王先生 is 79-yo male seen in the ED with respiratory distress with severe dyspnea and wheezing.

61

History of Present Illness (HPI)發生現在疾病之病程

• 王先生 was coming home from the grocery store when he became short of breath and wheezing carrying in his groceries.

• He could only say a couple words between breaths. His neighbor noticed him in distress and called 911.

• 王先生 experienced severe shortness of breath 6 months ago and was hospitalized for acute severe asthma.

62

Past Medical History (PMH)過去病史

• Diagnosis with asthma approximately 20 years ago, rheumatoid arthritis about 5 years ago, and benign prostatic hyperplasia last year.

• Patient using a herbal product to treat his benign prostatic hyperplasia.

• Admitted to hospital 3 times in the past 2 years for exacerbation of asthma.

• Previous office visit 5 weeks ago, documented a blood pressure reading of 150/95 mmHg.

63

Social History (SH)個人生活史

• Tobacco use: 1/2 pack/week

• Alcohol use: Six pack per week

• Caffeine use: 2 Cups of coffee every morning

64

Family History (FH)家族病史

• Mother died of an MI at age 68.

• Father died of lung cancer at age 75.

65

Medication Record (Prescription and OTC) (MedHx) 用藥史

• Furosemide 40 mg po q AM

• Albuterol inhaler 2 puffs qid prn

• Beclomethasone inhaler 1 puff qid

• Ibuprofen 800 mg po tid

• Herbal product with licorice po qd

• Acetaminophen po prn

66

Review of Systems (ROS)現有疾病或問題 (HPI 除外 )

• Wheezing and coughing

67

Physical Examination (PE)身體診察

• VS:– BP 160/100 mmHg

– HR 120 beats/min

– RR 31 rpm

– T 38.5℃– Ht 175 cm

– BW 95.4 kg

– BMI 31.2 (95.4/1.75x1.75)

• CHEST: Expiratory wheezes

68

Laboratory and Diagnostic Tests (Labs)檢驗數據及檢查報告

Potassium

3.8 mEq/L

Sodium

145 mEq/L

Serum creatinine 1 mg/dL

FBG

100 mg/dL

Total cholesterol 200 mg/dL

HDL

35 mg/dL

RBC

4.7 cells/mm3

Hgb 15 g/dL Hct 44%

PH

7.40

PaO2

55 mmHg

PaCO2

40 mmHg

69

Diagnosis診斷

• Primary:

1)Asthma

2)Hypertension

• Secondary:

1)Benign prostatic hyperplasia

2)Rheumatoid arthritis

• Problem list

70

Problem ListCurrent medical problems

Goal of therapy Measurable endpoint

Primary:

1)Asthma Symptom control

Prevent asthma episodes or attacks

PEFR

No DOE, SOB, PND

2)Hypertension Prevent CHD, Stroke and Nephropathy

BP

Secondary:

1)BPH Symptom control

DRE (digital rectal exam)

UFR (urine flow rate)

2)RA Improve QOL

Arrest or retard disease progress

Swollen & tender joints

RF, ESR, ANA, CBC

X-Ray

71

Current Drug-Therapy ProblemsSubjective and Objective

Problem(subjective and objective)

Current medication

S: Pertinent medical Hx:Asthma x 20 yrs; RA x 5 yrs; BPH x 1yr

ago; HTN x 5wks

ROS: respiratory distress with severe dyspnea ; wheezing and

coughing

Tobacco use: 0.5 pack/week ; alcohol use: 6 pack / week ;

caffeine use: 2 cups of coffee every morning

Use a herbal product to treat his BPH

Furosemide 40 mg po q AM

Albuterol inhaler 2 puffs qid prn

Beclomethasone inhaler 1 puff qid

Ibuprofen 800 mg po tid

Herbal product with licorice po qd

Acetaminophen po prn

O:

175cm , 95.4kg HR:120 BP:160/100 RR:31 T38.5℃Expiratory wheezes

PH 7.40; PaO2 55; PaCO2 40

Admitted to hospital 3 times/past 2 yrs for AE of asthma

BP 150/95 mmHg previous office visit 5 wks ago

72

Current Drug-Therapy ProblemsAssessment

Etiology

(or risk factors)

Evaluate need for therapy; evaluate current therapy (Evidence need for therapy evaluation)

AE of asthma Primary therapies for AE (most safely undertaken in a hospital or hospital-based ER)

Repetitive administration of rapid-acting inhaled β2-agonist

Early introduction of systemic glucocorticosteroids

Oxygen supplementation

Closely monitor response to treatment with serial measures of lung function

Inadequate response to treatment for HTN

D/C herbal product with licorice ( has been shown to have an aldosterone-like action)

Both ibuprofen and licorice can cause an inadequate response to HTN therapy

If BP remains elevated, the clinician should consider initiating anα-blocker

Inadequate BPH treatment

The preferred therapy for this pt may be α-blockers (the favorable effects on prostatism and dyslipidemia-decrease LDL-C and increase HDL-C

Postural hypotension is commonly experienced withα-1 blockers because of the direct action

The “first-dose phenomenon ” is characterized by transient dizziness,faintness, palpitations, and syncopy occurring within 3 hrs of the first dose.

73

Current Drug-Therapy ProblemsPlan

Recommended drug treatment, drug to be revised, further test

Goal and monitoring parameters (toxic and therapeutic)

Patient education

IV methylprednisolone 60-80 mg or Hydrocortisone 300-400 mg ; or oral prednisolone 0.5-1 mg/kg for 7-10 days

Decrease symptom

PEFR

(GINA 2004)

Report any in SOB, DOE, PND Techniques in use of medications

Smoking cessation

D/C herbal product with licorice BP check daily

BP in 1wk < 140/ 90 (JNC VIII)

Teach pt how to self measurement of BPRemind pt that home measurement

device should be checked regularly for accuracy

Lifestyle modification recommendations(5 modifications)

Usual dose :

Prazosin 2-30 mg ,bid-tid

Terazosin 1-20 mg ,qd-bid

Doxazosin 1-16mg ,qd

(first dose at hs)

Decrease symptom

(bladder outlet

obstruction, postvoid

residual urine

volume, reverse urinary

retention / RI

May be avoided by having the pt take the first dose and/or the first increase in dose at bedtime

74

謝謝聆聽 敬請指教尾端 Un Clos (A Close)- 塞尚 Cezanne 1890

時間分配• 9:20 ~ 10:50 分組討論與演練• 10:50 ~ 12:00 各組心得分享

– 第一組報告 10:50 – 11:00 ~ Type 2 DM--initiate OADs in a newly diagnosed DM patients

– 第二組報告 11:00 – 11:10 ~ Hypertension--inappropriate drug of choice and inadequate BP control for HTN

– 第三組報告 11:10 – 11:20 ~ Hyperlipidemia--initiate lipid lowing agents for a patient with high CV risks

– 第四組報告 11:20 – 11:30 ~ Obesity, metabolic syndrome--pharmacotherapy of obesity and metabolic syndrome

– 第五組報告 11:30 – 11:40 ~ 案例各問題補充報告– 第六組報告 11:40 – 11:50 ~ SOAP 格式心得報告– 11:50 ~ 12:00 輔導員分享

其他注意事項1.雖然有主題報告，仍有學員不熟悉 SOAP ，有時需解釋並分辨哪些屬於 "S"、哪些屬於 "O"、哪些屬於 "A"、哪些屬於 "P" ，請在課程報告中詳述佐以實例說明。

2.學員大部分都很怕講錯，一定要讓學員了解，課程是要訓練他們熟悉寫 SOAP 的思考模式和流程，所以上課時不要太在意所提出的 "PLAN" 對不對，而輔導員或主持人在講評時也儘量針對 SOAP 本身就好（除非真的建議的內容太離譜啦 ~）。

3.雖然練習的個案資料內容很豐富，但是要提醒學員在實際臨床時，有些資料不是光靠病歷閱讀來取得，尤其是針對藥物的部分（過去用藥史，有病史為何未用藥？ ...等等）。

4.善用手冊的 SOAP 表單，更能掌控 A 、 P呈現的重點。

註：請參考輔導員帶領小組討論的技巧與注意事項