SOAP Notes Rite in the Rain

[NousDefionsDoc]

I think I like this.

Cool Medic Stuff (http://wildmed.com/Merchant2/merchant.mv?Screen=PROD&Store_Code=WMAG&Product_Code=AWSN&Category_Code=PUBS)

[Surgicalcric]

SOAP...uggggg.

[NousDefionsDoc]

You got something better?

[Surgicalcric]

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.

[NousDefionsDoc]

Go ahead.

[shadowflyer]

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

[Surgicalcric]

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.

[NousDefionsDoc]

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

[Surgicalcric]

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

[NousDefionsDoc]

What do you mean repeats itself?

[Surgicalcric]

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?

[NousDefionsDoc]

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

What's CHART?

[Eagle5US]

Originally posted by NousDefionsDoc
Well, not being able to write them correctly hardly invalidates the system.

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

Eagle

[Surgicalcric]

I did not say the system was invalid did I?

[NousDefionsDoc]

Originally posted by Surgicalcric
I did not say the system was invalid did I?

No, no you didn't.

SOAP...uggggg.

SOAP just repeats itself...

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

[Sacamuelas]

The ONLY valid argument I have ever seen against the SOAP method was its mandated use on routine/simple/non treatment notations like a phone call followup or a post op check. In those limited circumstances, it seems a waste of time to have to document each part of a SOAP format notation just to say you called the patient and he said he was Ok.

Otherwise,

S- subjective information
o- objective information
A- assessment/DX
P- prognosis/Procedures performed

How in the #%# could it get any easier than that. ANyone in the medical field not intellligent enough to figure it out shouldn't get to play in the big leagues. LOL

Crip- your method breaks it down into basically the same catagories...just out of order and much more likely to leave out info in the entry during documentation.... :munchin

[Surgicalcric]

Sorry 'bout that NDD.

Having to read PCR's every shift has jaded me a bit. It seems like I read and reread the same things over and again.

Its not the fault of the system, but that of the individual writing the report.

Think I will get back to those reports now...lol.

[NousDefionsDoc]

'sides, how cool would it be to tell Sofia "Go ahead and bandage Mr. Harsey on up there, darlin'. And don't forget to SOAP him real good." LOL

[Surgicalcric]

Saca:

Not my method. Its the one we use here at the FD.

I dont understand how it would be easier to forget to document something with this method.

I dont mind the SOAP method. I am just used to the one we use here.

NDD:

I am sure Mr Harsey would not mind.

[Sacamuelas]

My post wasn't aimed at you Cric. Just aimed at anti-SOAP comments in general.

It is easy to remember, prevents you from leaving out information...and allows for quick acquisition of the type info you are looking for without reading the entire note.

Your method is probably very good for EMT areas. I think the SOAP method has better versatility for the clinical side of the house. Not trying to argue really... just my .02.

[Doc T]

I learned soap different than Sacamuelas...

S: subjective
O: objective
A: assessment
P: plan

I guess prognosis was part of assessment and procedures each got a separate procedure note.

See NDD....maybe its not so simple...lol

doc t.

[NousDefionsDoc]

Originally posted by Doc T
I learned soap different than Sacamuelas...

S: subjective
O: objective
A: assessment
P: plan

I guess prognosis was part of assessment and procedures each got a separate procedure note.

See NDD....maybe its not so simple...lol

doc t.

The "P" is Plan. Sacamuelas is a dentist. Not his fault he's screwed up. LOL

[Sacamuelas]

LOL ....

Yes... I learned it as P officially as plan.. but procedure and prognosis substitute in depending on the type of notation.

In my daily work, I usually put the plan/with prognosis last in the P portion of the note.

[Surgicalcric]

Good cover up there Saca... :D

[NousDefionsDoc]

Very nice crawfishing. Excellent work.

[24601]

I never learned SOAP. The system back home liked CHART.

Chief complaint
Hx
Assessment
Rx
Transport


The run forms were printed up with that on it, so that we learned. Once I'm settled and unpacked, I'll scan on if you like.