# HELP! Working on my 5 Soap notes for EMT 1 course



## absentsanity (Apr 29, 2012)

Im getting confused by my soap note handout and what soap acronym actually means... It says sample hx should be in objective but aren't questions like pertinent negatives subjective?  I don't know maybe some of you could give me some notes, im so close to finishing this class just seemed to have been in space for the few times we went over this.

Here is what I have for one of my notes:

S:
I have a 77 year old male  whose chief complaint is hip pain, states his level of pain is 1 out of 10.
Patient states he tripped and fell while fixing a gate at his church around 1:30pm, patient was found in an unknown position on cement driveway.

O:

Head to toe findings revealed a bump on the left hip and lateral rotation of left leg while lying supine patient denies being able to rotate left leg to a neutral position. Good CSM’s on left leg.  

Vitals after arrival at ED 2:20pm:
LoC: A&OX4
Heart Rate: 69 strong and regular
Respiration Rate: 14 unlabored
Skin: Pink Warm and Dry
0xygen sat: 98
BP: 178/70
Pupils: PEARL

Patient denies drinking, street drugs, marijuana use, allergies to any medications, seizures, previous hip injury, heart problems, bridge dentures, and stroke.

Patient has point tenderness on his left hip, pain was rated 1 out of 10 in supine position, Patient is a type 2 diabetic and has a hernia, Last ins and outs are unknown. Medications taken are unknown (I didn’t ask, nurse seemed to know him).

A:
Possible Hip Fracture

P:
Patient was given warm blanket and ice on his hip, and then taken for an X-ray.
X-ray revealed a hip fracture and patient was scheduled for surgery the next morning. Monitoring patient for any changes.


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## Aidey (Apr 29, 2012)

Read the 5 part series here.


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## RocketMedic (Apr 29, 2012)

Chart is better.

Chief Complaint 
History (including long-term medical history)
Assessment (including your preliminary field diagnosis)
Response (your treatments go here)
Timeline

It's much easier to figure out what's going on when these are reviewed.


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## Aidey (Apr 29, 2012)

CHART and SOAP are really the same thing.

C - Chief complaint.
H - History.
A - Assessment (physical exam in this case).
R - Rendered care (treatment).
T -  Transport.

S - Subjective, which are things that you are told which includes CC and HX.
O - Objective, which are things you find, which includes physical exam and vitals.
A - Assessment , your assessment of the pt. 
P - Plan, including treatment, response to treatment and transport. 

Honestly, I can switch back and forth with very little issue. The end is the only part that is different. CHART (and its variations) tend to work better for pre hospital. Treatment, response and transport is a lot to stick in the plan section.


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## absentsanity (Apr 29, 2012)

Yup, this is just the format she wants us to use. Thanks for the info on chart too scared to try something different. Basically just confused why pertinent negs from sample hx wouldn't be in subjective if they were relayed to me by the patient.


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## Maine iac (Apr 29, 2012)

Anything your pt tells you is subjective and anything you observe is objective.

You can't see nausea (Subjective) but you can see vomiting (Subjective and Objective).

If your pt is doubled over the toilet stating "I feel soooo sick" you can't say they have nausea, but you could state there is vomit in the toilet and they look distressed. 

Your pt can complain of difficulty breathing (Subjective) but you can also see difficulty breathing e.g. work of breathing (Objective). In most cases the pt states they can't breathing, but they appear to be moving air just fine so I state in my findings (Objective) there is no dyspnea noted.

The SAMPLE questions will be split up between both subjective and objective depending on what the pt is complaining of. 

In your example they are complaining of a hurt hip. The Signs/Symptoms are also Objective/Subjective. 

Most of the pt's history will be subjective. Even if you are reading a nursing home's demographics sheet with past medical hc, medications, and allergies just for simplicities sake keep it in the Subjective.


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## Sasha (Apr 29, 2012)

It's easier to make up 5 patients who all refuse assessment and transport. 

Easiest soaps I ever wrote.


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