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 received the care and the response to that careresponse to 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, Patient location in vehicle, seatbelt, airbag, speedseatbelt, airbag, speed

Vehicular damage, pt Vehicular damage, pt compartment intrusioncompartment intrusion

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 Repeat – q 5 unstable, q 10 for

stablestable 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 AMI

oror 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.