Download - S.O.A.P. Charting
S.O.A.P.S.O.A.P.ChartingCharting
Actual Medical ChartsActual Medical Charts
The skin was moist and dryThe skin was moist and dry Bleeding started in the rectal Bleeding started in the rectal
area and continued all the way area and continued all the way to Los Angelesto Los Angeles
She is numb from her toes downShe is numb from her toes down Occasional, constant, infrequent Occasional, constant, infrequent
headachesheadaches Patient was alert and Patient was alert and
unresponsiveunresponsive
Actual Medical ChartsActual Medical Charts
When she fainted, her eyes When she fainted, her eyes rolled around the room rolled around the room
The patient was in his usual The patient was in his usual state of good health until his state of good health until his airplane ran out of gas and airplane ran out of gas and crashedcrashed
SOAP ProvidesSOAP Provides
Data base to plan patient careData base to plan patient care Communication between health Communication between health
care providerscare providers Written evidence of why patient Written evidence of why patient
received the care and the response received the care and the response to that careto that care
A way to review, study and A way to review, study and evaluate patient careevaluate patient care
A detailed legal recordA detailed legal record
The AcronymThe Acronym
S – SubjectiveS – Subjective O – ObjectiveO – Objective A – AssessmentA – Assessment P – PlanP – Plan
The RequirementsThe Requirements
Agency/SchoolAgency/School Sets the standards for Sets the standards for
documentation and abbreviationsdocumentation and abbreviations Has policy for when and what will Has policy for when and what will
be documentedbe documented
Demographic InformationDemographic Information
Verification Form Verification Form NameName HospitalHospital DepartmentDepartment DateDate Shift timeShift time Preceptor signsPreceptor signs
Flow ChartFlow Chart TimesTimes 2 sets v/s2 sets v/s Pt medsPt meds AllergiesAllergies
NarrativeNarrative S.O.A.P. S.O.A.P.
formatformat AttachmentsAttachments
EKG stripsEKG strips
ALWAYSALWAYS
Be HonestBe Honest Be ObjectiveBe Objective Be AccurateBe Accurate Be CompleteBe Complete Be LegibleBe Legible
Use CCC Use CCC approved approved abbreviationsabbreviations
Watch your Watch your spellingspelling
Use Charting Use Charting TemplatesTemplates MedicalMedical TraumaTrauma
NEVERNEVER
Use wording that can lookUse wording that can look BiasedBiased PrejudicedPrejudiced JudgmentalJudgmental
Make up abbreviations that don’t Make up abbreviations that don’t existexist
Willingly falsify a recordWillingly falsify a record
SubjectiveSubjective
Definition:Definition: Information that you are told or Information that you are told or
read in regards to the patient - read in regards to the patient - you have no proof as to the you have no proof as to the validity of subjective informationvalidity of subjective information
Everything that you are toldEverything that you are told
SubjectiveSubjective
InformantInformant Chief ComplaintChief Complaint
History of Present Illness/Injury History of Present Illness/Injury (HPI)(HPI)
SAMPLE HistorySAMPLE History Special ConsiderationsSpecial Considerations
InformantInformant
The PatientThe Patient RelativesRelatives WitnessesWitnesses Nurse/MDNurse/MD Law Law
EnforcementEnforcement ParamedicParamedic
Pt wife states…Pt wife states… The hospital The hospital
chartchart
Chief ComplaintChief Complaint
Why EMS was activatedWhy EMS was activated What the patient (or bystander) What the patient (or bystander)
states is the reason for calling states is the reason for calling 911911
History of Present History of Present Illness/InjuryIllness/Injury What happened today to cause What happened today to cause
the caller to activate EMSthe caller to activate EMS Use OPQRST mnemonicUse OPQRST mnemonic Pertinent NegativesPertinent Negatives
OPQRSTOPQRST
O – Onset O – Onset P – Provocation, PalliationP – Provocation, Palliation Q – QualityQ – Quality R – Radiation, Region, RateR – Radiation, Region, Rate S – Severity S – Severity
0 – 10 scale0 – 10 scale T – Time since onset, TreatmentT – Time since onset, Treatment
Self, home or doctorSelf, home or doctor
SAMPLESAMPLE
S – Signs and SymptomsS – Signs and Symptoms A – AllergiesA – Allergies M – MedicationsM – Medications P – Past Medical History P – Past Medical History
(PMHx)(PMHx) L – Last Oral IntakeL – Last Oral Intake E – Events leading up to eventE – Events leading up to event
Special ConsiderationsSpecial Considerations
Document pertinent positives & Document pertinent positives & negativesnegatives
Direct quotes need quotation marksDirect quotes need quotation marks Dying patient declarations need to be Dying patient declarations need to be
documented verbatimdocumented verbatim Don’t wander, keep to matter at Don’t wander, keep to matter at
handhand Document LMP for all women of Document LMP for all women of
child-bearing agechild-bearing age
ExampleExample
Dispatched to male with chest pain. Pt c/o Dispatched to male with chest pain. Pt c/o substernal chest pain that started suddenly substernal chest pain that started suddenly 2 hours ago while working horses in the 2 hours ago while working horses in the pasture. Pt states pain gets worse with pasture. Pt states pain gets worse with exertion and is unrelieved by rest. Pt exertion and is unrelieved by rest. Pt describes the pain as a dull, squeezing describes the pain as a dull, squeezing sensation that radiates to his neck, left arm sensation that radiates to his neck, left arm and jaw. Pt states pain is 8/10, states took and jaw. Pt states pain is 8/10, states took 2 of his friends nitroglycerin pills without 2 of his friends nitroglycerin pills without relief. Pt also c/o nausea, lightheadedness, relief. Pt also c/o nausea, lightheadedness, diaphoresis, denies vomiting, LOC or diaphoresis, denies vomiting, LOC or previous event like this.previous event like this.
Example cont’dExample cont’d
PMHx – HTN, hypothyroid, PMHx – HTN, hypothyroid, hypercholesterolemia, hypercholesterolemia, appendectomyappendectomy
Meds – HCTZ, Synthroid, Zocor, Meds – HCTZ, Synthroid, Zocor, Baby ASABaby ASA
Allergies - PCNAllergies - PCN
ObjectiveObjective
Information that is gathered from Information that is gathered from the primary and secondary the primary and secondary examexam
Everything the examiner can Everything the examiner can see, hear, touch and smellsee, hear, touch and smell
ObjectiveObjective
Initial AssessmentInitial Assessment Focused AssessmentFocused Assessment Trauma DocumentationTrauma Documentation Vital Signs (usually documented Vital Signs (usually documented
in flow chart)in flow chart)
Primary SurveyPrimary Survey
Location and position foundLocation and position found Approximate age, weight, sex, raceApproximate age, weight, sex, race Level of ConsciousnessLevel of Consciousness
AVPU – alert, verbal, painful, unconsciousAVPU – alert, verbal, painful, unconscious AAO (CAO) X 4 or PPTE– awake AAO (CAO) X 4 or PPTE– awake
(conscious), alert and oriented to person, (conscious), alert and oriented to person, place, time and eventplace, time and event
GCSGCS Skin Color, Temperature, Turgor, Skin Color, Temperature, Turgor,
MoistureMoisture Patient ConditionPatient Condition
i.e. tripod position, pursed lip breathing, i.e. tripod position, pursed lip breathing, accessory muscle usageaccessory muscle usage
Secondary SurveySecondary Survey
HeadHead HEENT: Head, Eyes, Ears, Nose, HEENT: Head, Eyes, Ears, Nose,
ThroatThroat Pupils, Facial SymmetryPupils, Facial Symmetry
Neck: Neck: JVD, tracheal deviation, c-spine JVD, tracheal deviation, c-spine
tenderness, nuchal rigidity, tenderness, nuchal rigidity, accessory muscle usageaccessory muscle usage
Secondary Survey cont’dSecondary Survey cont’d
Chest:Chest: Symmetry, barrel chest, flail Symmetry, barrel chest, flail
segmentssegments RetractionsRetractions Lung soundsLung sounds Respiratory patternRespiratory pattern
Cheyne-Stokes, Kussmaul, Ataxic, Cheyne-Stokes, Kussmaul, Ataxic, etcetc
Secondary Survey cont’dSecondary Survey cont’d
Back:Back: Be sure to visualize, or document Be sure to visualize, or document
why you could notwhy you could not Abdomen (ABD):Abdomen (ABD):
Tenderness, guarding, rigidity, Tenderness, guarding, rigidity, pulsatile masspulsatile mass
Palpate all quadrantsPalpate all quadrants
Secondary Survey cont’dSecondary Survey cont’d
PelvisPelvis TendernessTenderness Urinary or Bowel IncontinenceUrinary or Bowel Incontinence
Lower ExtremitiesLower Extremities PMS –pulse, movement and PMS –pulse, movement and
sensationsensation Pedal EdemaPedal Edema
ObjectiveObjective
EKG – document the rhythm and attach strip
Trauma DocumentationTrauma Documentation MVCMVC
Patient location in vehicle, seatbelt, Patient location in vehicle, seatbelt, airbag, speedairbag, speed
Vehicular damage, pt compartment Vehicular damage, pt compartment intrusionintrusion
FallsFalls Approximate distanceApproximate distance Surface landed onSurface landed on
GSWGSW If known, caliber and proximityIf known, caliber and proximity
Trauma DocumentationTrauma Documentation
StabbingStabbing If known, length of knifeIf known, length of knife
BurnsBurns Percentage and severity using Percentage and severity using
Rule of 9’sRule of 9’s Other types of traumaOther types of trauma
Mechanism, weapons, etcMechanism, weapons, etc
Vital SignsVital Signs
At least 2 full sets documented on all At least 2 full sets documented on all transports. transports. Full set = Pulse, Resp Rate, BP, SaOFull set = Pulse, Resp Rate, BP, SaO22, ,
pain scalepain scale Repeat – q 5 unstable, q 10 for stableRepeat – q 5 unstable, q 10 for stable Repeat after administration of any Repeat after administration of any
medicationmedication At least one blood pressure should At least one blood pressure should
be auscultated to verify accuracy of be auscultated to verify accuracy of NIBP preferably before NIBP is NIBP preferably before NIBP is placedplaced
AssessmentAssessment
AssessmentAssessment
Your impression of patient’s Your impression of patient’s medical problemmedical problem
We are NOT doctors and we We are NOT doctors and we cannot diagnose! cannot diagnose!
Precede impression with poss., Precede impression with poss., prob., R/Oprob., R/O
AssessmentAssessment
R/O AMIR/O AMIoror Prob. AMI, poss. Unstable Prob. AMI, poss. Unstable
Angina, poss. Severe GERDAngina, poss. Severe GERD
PlanPlan
Chronological order of treatment Chronological order of treatment and responses to that treatmentand responses to that treatment
Everything you did from the time Everything you did from the time you arrived on scene to the you arrived on scene to the hand-off at the hospitalhand-off at the hospital
Written in a timeline, with times Written in a timeline, with times documented on all treatmentdocumented on all treatment
Treatment DocumentationTreatment DocumentationOxygenationOxygenation
Liter FlowLiter Flow Delivery SystemDelivery System
Nasal Cannula (NC)Nasal Cannula (NC) Non-rebreather (NRB)Non-rebreather (NRB) Bag-Valve-Mask (BVM)Bag-Valve-Mask (BVM)
Pt response or lackPt response or lack
Treatment DocumentationTreatment DocumentationIV TherapyIV Therapy
Solution (NS, LR, D5W)Solution (NS, LR, D5W) Flow Rate (TKO, KVO, WO)Flow Rate (TKO, KVO, WO) Gauge and siteGauge and site Number of attempts and who Number of attempts and who
attemptedattempted Any effects noted?Any effects noted?
Treatment DocumentationTreatment DocumentationPharmacologyPharmacology
5 Rights 5 Rights Patient, Drug, Dose, Route, TimePatient, Drug, Dose, Route, Time
Time and Who administeredTime and Who administered Effects, positive, negative, or Effects, positive, negative, or
nonenone Repeat VS after each adminRepeat VS after each admin
Treatment DocumentationTreatment DocumentationFracturesFractures
Type of ImmobilizationType of Immobilization Sensory, motor and circulatory Sensory, motor and circulatory
function before and after function before and after immobilization immobilization
andand At completion of patient contactAt completion of patient contact
Pearls of WisdomPearls of Wisdom
If it wasn’t documented it wasn’t If it wasn’t documented it wasn’t done!done!
DOCUMENT, DOCUMENT, DOCUMENT, DOCUMENT, DOCUMENTDOCUMENT
Remember, you may end up in Remember, you may end up in court one day with the chart you court one day with the chart you write, be sure it is thorough.write, be sure it is thorough.