CONSTRUCTION OF A MODEL OF PHARMACEUTICAL EVOLUTION IN PATIENT´S MEDICAL RECORDS

Abstract

Considering the need to standardize the elaboration of the registry of the care provided to the patient by Health Workers, a model of pharmaceutical evolution record is proposed to be used by Clinical Pharmacists in a hospital scope. From a literature review of the narrative type, it began with the problem question:’’ what and how should the clinical pharmacist register in the patient’s medical records at the hospital scope after the pharmaceutical anamnesis?’’, followed by for the search of articles in databases as Lilacs, Scielo and PubMed, and then a critical analysis and selection of papers that supported the construction of the proposed pharmaceutical evolution. Ten articles and 2 guidelines were selected, in which the organization of data was chosen from SOAP, which is an acronym in which each initial letter represents one of the sections of the notes of evolution, that is, subjective data (S), objective data (O), assessment (A) and planning (P). The data aimed to ensure that all patient pharmacotherapy is adequate to treat the involved health problem. Documenting the pharmaceutical care, in a standard form, led to the optimization of patient pharmacotherapy, and showed to be a necessary step to improve the communication in multi-professional teams. Therefore, the development of a pharmaceutical evolution SOAP can be useful to improve this point, by addressing what information and how to organize them.