S. O. A. P. Charting Actual Medical Charts



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S.O.A.P. Charting

Actual Medical Charts

  • The skin was moist and dry
  • Bleeding started in the rectal area and continued all the way to Los Angeles
  • She is numb from her toes down
  • Occasional, constant, infrequent headaches
  • Patient was alert and unresponsive

Actual Medical Charts

  • When she fainted, her eyes rolled around the room
  • The patient was in his usual state of good health until his airplane ran out of gas and crashed

SOAP Provides

  • Data base to plan patient care
  • Communication between health care providers
  • Written evidence of why patient received the care and the response to that care
  • A way to review, study and evaluate patient care
  • A detailed legal record

The Acronym

  • S – Subjective
  • O – Objective
  • A – Assessment
  • P – Plan

The Requirements

  • Agency/School
    • Sets the standards for documentation and abbreviations
    • Has policy for when and what will be documented

Demographic Information

  • Verification Form
    • Name
    • Hospital
    • Department
    • Date
    • Shift time
    • Preceptor signs
  • Flow Chart
    • Times
    • 2 sets v/s
    • Pt meds
    • Allergies
  • Narrative
    • S.O.A.P. format
  • Attachments
    • EKG strips

ALWAYS

  • Be Honest
  • Be Objective
  • Be Accurate
  • Be Complete
  • Be Legible
  • Use CCC approved abbreviations
  • Watch your spelling
  • Use Charting Templates
    • Medical
    • Trauma

NEVER

  • Use wording that can look
    • Biased
    • Prejudiced
    • Judgmental
  • Make up abbreviations that don’t exist
  • Willingly falsify a record

Subjective

  • Definition:
    • Information that you are told or read in regards to the patient - you have no proof as to the validity of subjective information
  • Everything that you are told

Subjective

  • Informant
  • Chief Complaint
    • History of Present Illness/Injury (HPI)
  • SAMPLE History
  • Special Considerations

Informant

  • The Patient
  • Relatives
  • Witnesses
  • Nurse/MD
  • Law Enforcement
  • Paramedic
  • Pt wife states…
  • The hospital chart

Chief Complaint

  • Why EMS was activated
  • What the patient (or bystander) states is the reason for calling 911

History of Present Illness/Injury

  • What happened today to cause the caller to activate EMS
  • Use OPQRST mnemonic
  • Pertinent Negatives

OPQRST

  • O – Onset
  • P – Provocation, Palliation
  • Q – Quality
  • R – Radiation, Region, Rate
  • S – Severity
    • 0 – 10 scale
  • T – Time since onset, Treatment
    • Self, home or doctor

SAMPLE

  • S – Signs and Symptoms
  • A – Allergies
  • M – Medications
  • P – Past Medical History (PMHx)
  • L – Last Oral Intake
  • E – Events leading up to event

Special Considerations

  • Document pertinent positives & negatives
  • Direct quotes need quotation marks
  • Don’t wander, keep to matter at hand
  • Document LMP for all women of child-bearing age

Example

  • Dispatched to male with chest pain. Pt c/o substernal chest pain that started suddenly 2 hours ago while working horses in the pasture. Pt states pain gets worse with exertion and is unrelieved by rest. Pt describes the pain as a dull, squeezing sensation that radiates to his neck, left arm and jaw. Pt states pain is 8/10, states took 2 of his friends nitroglycerin pills without relief. Pt also c/o nausea, lightheadedness, diaphoresis, denies vomiting, LOC or previous event like this.

Example cont’d

  • PMHx – HTN, hypothyroid, hypercholesterolemia, appendectomy
  • Meds – HCTZ, Synthroid, Zocor, Baby ASA
  • Allergies - PCN

Objective

  • Information that is gathered from the primary and secondary exam
  • Everything the examiner can see, hear, touch and smell

Objective

  • Initial Assessment
  • Focused Assessment
  • Trauma Documentation
  • Vital Signs (usually documented in flow chart)

Primary Survey

  • Location and position found
  • Approximate age, weight, sex, race
  • Level of Consciousness
    • AVPU – alert, verbal, painful, unconscious
    • AAO (CAO) X 4 or PPTE– awake (conscious), alert and oriented to person, place, time and event
    • GCS
  • Skin Color, Temperature, Turgor, Moisture
  • Patient Condition
    • i.e. tripod position, pursed lip breathing, accessory muscle usage

Secondary Survey

  • Head
  • Neck:
    • JVD, tracheal deviation, c-spine tenderness, nuchal rigidity, accessory muscle usage

Secondary Survey cont’d

  • Chest:
    • Symmetry, barrel chest, flail segments
    • Retractions
    • Lung sounds
    • Respiratory pattern
      • Cheyne-Stokes, Kussmaul, Ataxic, etc

Secondary Survey cont’d

  • Back:
    • Be sure to visualize, or document why you could not
  • Abdomen (ABD):
    • Tenderness, guarding, rigidity, pulsatile mass
    • Palpate all quadrants

Secondary Survey cont’d

  • Pelvis
    • Tenderness
    • Urinary or Bowel Incontinence
  • Lower Extremities
    • PMS –pulse, movement and sensation
    • Pedal Edema

Objective

  • EKG – document the rhythm and attach strip

Trauma Documentation

  • MVC
    • Patient location in vehicle, seatbelt, airbag, speed
    • Vehicular damage, pt compartment intrusion
  • Falls
    • Approximate distance
    • Surface landed on
  • GSW
    • If known, caliber and proximity

Trauma Documentation

  • Stabbing
    • If known, length of knife
  • Burns
    • Percentage and severity using Rule of 9’s
  • Other types of trauma
    • Mechanism, weapons, etc

Vital Signs

  • At least 2 full sets documented on all transports.
    • Full set = Pulse, Resp Rate, BP, SaO2, pain scale
  • Repeat – q 5 unstable, q 10 for stable
  • Repeat after administration of any medication
  • At least one blood pressure should be auscultated to verify accuracy of NIBP preferably before NIBP is placed

Assessment

Assessment

  • Your impression of patient’s medical problem
  • We are NOT doctors and we cannot diagnose!
  • Precede impression with poss., prob., R/O

Assessment

  • R/O AMI
  • or
  • Prob. AMI, poss. Unstable Angina, poss. Severe GERD

Plan

  • Chronological order of treatment and responses to that treatment
  • Everything you did from the time you arrived on scene to the hand-off at the hospital
  • Written in a timeline, with times documented on all treatment

Treatment Documentation Oxygenation

  • Liter Flow
  • Delivery System
    • Nasal Cannula (NC)
    • Non-rebreather (NRB)
    • Bag-Valve-Mask (BVM)
  • Pt response or lack

Treatment Documentation IV Therapy

Treatment Documentation Pharmacology

  • 5 Rights
    • Patient, Drug, Dose, Route, Time
  • Time and Who administered
  • Effects, positive, negative, or none
  • Repeat VS after each admin

Treatment Documentation Fractures

  • Type of Immobilization
  • Sensory, motor and circulatory function before and after immobilization
  • and
  • At completion of patient contact

Pearls of Wisdom

  • If it wasn’t documented it wasn’t done!
  • DOCUMENT, DOCUMENT, DOCUMENT
  • Remember, you may end up in court one day with the chart you write, be sure it is thorough.

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