SOAP Notes Rite in the Rain
 

I think I like this.

Cool Medic Stuff

SOAP...uggggg.

You got something better?

I have something better for EMS specific calls. I do not have one that is a 'one-size fits-all' system similar to that of the SOAP method.

If you are interested I could share it here.

Go ahead.

I would be interested in the EMS specific one myself.



Side Note:
In Medic class today we went over about 10 weeks of Anatomy and Physiology in about 6 hrs. My brain is on overload. I am glad I took that A/P class last quarter to get ready for Medic school. Studying at least 2-3 hrs a night will be a common practice at my house from here on out.

Best Regards,

Jason

DX: This section is to tell general details about the patient (age, sex,), why EMS summoned and what PT is being treated/transported for.

1º: Primary Survey - how patient found; A,B,C, & D.

2º: Secondary Survey- Physical findings both Pos & Neg as they relate to complaint; pupils, lung sounds, DCAP/BTLS, EKG, SAO2, ETCO2, etc...

TX: Treatment rendered, facility transported to, personnel PT care transferred to.

Δ: Changes in patient condition pos & neg.

HX: past pertinent medical history, MEDS, allergies, MD’s
____________________
Sample from a recent call

DX: EMS summoned to residence of 54 y/o/w/♂ c/o chest pain w/o relief after SL NTG x 2.

1º: PT found seated upright; A,B,C+; A&O to person, place, time, events.

2º: PT c/o crushing type pain over mediastinum which began while mowing lawn, pain rediating down L arm, Pain 8 on 10 scale, non-reproducible on palm or respiration and began ≈30 min PTA EMS. Pain has not been relieved with ↑self TX. PT also c/o assoc severe SOB. B/P-80/54, Pulse-50/irreg, Resp-24/labored. PERRL, L/S-Rhonchi bilaterally w/ = mvmt, SAO2-88% on RA, ETCO2-32mmHg. LP-12 showing SB @ 48-54 BPM with frequent PVC’s non-perfusing. 12-lead showing acute inferio-septal MI.

TX: O2 NRB at 15-lpm, IV L hand/18ga NS KVO, IV R hand/18ga NS @ KVO. NTG .04mg SL(RPT x2@ 5min intervals), MS 5mg IVP (RPTx1 @ 10 min), Lasix 100mg IVP, Dopamine drip titrated @ 400mcg/min, T-PA 10mg IVP over 2min/ drip at 50mg/hr, –>F/W–>M-106. T-port Code3 to GMH ER. Oral report enroute to MCD-12. Transferred to bed CC#4 and left ICO RN and MD @ bedside after report given.

Δ: SAO2-↑94% with O2, B/P-↑98/64, Pt states no relief of pain but some relief of SOB, no change w/ follow on 12-lead.

HX: MD-Cano, NKDA, MEDS: NTG, PMH: Angina.

Crip, that's a SOAP note without the easy to remember pnuemonic.
DX1o2oTXAHX doesn't spell anything.

SOAP just repeats itself...

I did not say our method here was a nifty acronym. I like the CHART method as well.

Now, if you will excuse me I need to take a few pics of my FUGLY mk-III on my Marauder for posting purposes. :D

What do you mean repeats itself?

I find most people cant tell the difference between the S and O. They tend to repeat themsleves.

There is also an Evaluate on the end now.

Did you learn the SOAP method as a part of your MOS training?

Well, not being able to write them correctly hardly invalidates the system.

What's CHART?

I was waiting for that..
Tee Hee Hee :D

Eagle

I did not say the system was invalid did I?

No, no you didn't.

My bad, sorry. Carry on. At ease, all that Army stuff.:D