Example SOAP's/PAN's

[teedubbyaw]

Working on bettering my documentation -- any good examples out there that really cover everything?

 

[OnceAnEMT]

Never heard of a PAN before, what is that? I hate seeing SOAP used for the emergency world. I guess it works, but I feel there are better tools. To me it is best put to use for long-term/repetitive care, as seen in PT or AT or any sort of rehab.

 

[teedubbyaw]

Never heard of a PAN before, what is that? I hate seeing SOAP used for the emergency world. I guess it works, but I feel there are better tools. To me it is best put to use for long-term/repetitive care, as seen in PT or AT or any sort of rehab.

Patient Assessment Narrative

 

[Drax]

Never heard of a PAN before, what is that? I hate seeing SOAP used for the emergency world. I guess it works, but I feel there are better tools. To me it is best put to use for long-term/repetitive care, as seen in PT or AT or any sort of rehab.

I feel like there could potentially be a better tool for EMS Specifically but that said, I have not seen one (especially in mnemonic form). I think SOAP is good though because it is in language that hospitals and ER Staff use, albeit SOAPE.

Have you seen a different tool is use?

 

[TransportJockey]

I feel like there could potentially be a better tool for EMS Specifically but that said, I have not seen one (especially in mnemonic form). I think SOAP is good though because it is in language that hospitals and ER Staff use, albeit SOAPE.

Have you seen a different tool is use?

D-CHART-E and RESCUE are two that I"m familiar with. I've never worked at a service that allowed SOAP notation

 

[Carlos Danger]

I actually think SOAP is perfect for EMS (though I prefer SOAPIER, which just adds ("intervention" and "evaluation"), but the key is that you have to document by exception, which many in EMS have unfortunately been brainwashed into thinking will get them hauled into court the very next day.

 

[Aprz]

I actually think SOAP is perfect for EMS (though I prefer SOAPIER, which just adds ("intervention" and "evaluation"), but the key is that you have to document by exception, which many in EMS have unfortunately been brainwashed into thinking will get them hauled into court the very next day.

What is the R for?

And what do you mean by exception?

 

[Drax]

D-CHART-E and RESCUE are two that I"m familiar with. I've never worked at a service that allowed SOAP notation

I assume these mnemonics are described on a "hand-off" sheet when transferred over to the hospital staff?

SOAP is a commonly used device for fire service in the Western Washington area.

Subjective (hx present, past): This is information told to the examiner that he or she could not directly observe. The information required in this section is easily remembered by two mnemonics: SAMPLE (Signs and symptoms, Allergies, Medications, Pertinent past medical history, Last oral intake, and Events leading to the 911 call) and OPQRST (Onset, Provokers, Quality, Radiation, Severity and Time).

Objective (findings): The objective portion of the narrative section contains details the examiner observed directly. This is where the patient assessment is documented.

Assessment (findings): This is the examiner's impression of what the medical problem might be. This is not a diagnosis. The assessment should be written as a two-part statement. The first part should state simply whatever the examiner found wrong with the patient: “Chest discomfort,” for example. The second part of the assessment is the “Rule Out” section, which is written in a particular way, The examiner's impression of the patient's problem should be preceded by the abbreviation “R/O” (“Rule Out”). For example, the assessment of a patient with chest discomfort and shortness of breath might look like this: A/Chest Discomfort 1) R/O ACS 2) R/O CHF.

Plan (care events): This section of the narrative should detail the care the patient received and his or her response to the treatment. This Washington state-approved tool is designed to help emergency medical service providers prioritize treatment and transport during a mass casualty incident.

This from Thurston County's EMS Protocol

 

[TransportJockey]

I assume these mnemonics are described on a "hand-off" sheet when transferred over to the hospital staff?

SOAP is a commonly used device for fire service in the Western Washington area.



This from Thurston County's EMS Protocol

We dont provide narratives in the handoff sheets. Just basic information and notes in the field forms. Narrative and completed charts are faxed to them.

 

[Drax]

We dont provide narratives in the handoff sheets. Just basic information and notes in the field forms. Narrative and completed charts are faxed to them.

Oh. Just a verbal handoff then?

 

[JPINFV]

I assume these mnemonics are described on a "hand-off" sheet when transferred over to the hospital staff?

SOAP is a commonly used device for fire service in the Western Washington area.



This from Thurston County's EMS Protocol

Aww, cute. They think that by using the words "rule out" that the assessment isn't a working and differential diagnosis.

 

[JPINFV]

It wasn't until I got into medical school that I came to like SOAP. The problem with SOAP, as used in EMS, is that it often doesn't include the subsections. The subjective isn't a single continuous paragraph. It should be bullet points with a HPI ("history of present illness" which contains OPQRST, associated symptoms, pertinent negatives, additional information for what's going on), history, allergy meds, social history, review of systems). Similarly the objective section should similarly be broken down by paragraphs by system starting with vital signs and general exam (ok. arguably VS are normally documented elsewhere, and that's fine).

The nice thing about SOAP is that it's flexible. If there's no reason to examine the extremities for things like range of motion and sensation (edema secondary to CHF, for example, should be in the cardiac section, not the extremities section) then it doesn't have to be there. It's as flexible as the provider wants it to be.

 

[Carlos Danger]

What is the R for?

And what do you mean by exception?

I was taught SOAPIER so I guess I added the "R" just out of habit, but it just adds "re-assessment", which I think is a little redundant.

Charting "by exception" means that you only chart what seems clinically relevant; you don't bother documenting assessment findings that are normal or that have nothing to do with the complaints. Not charting breath sounds on a healthy patient who twisted his ankle, for instance. It doesn't meant you didn't listen, it means that they were normal, and therefore not worth taking the time to chart on, or that listening simply wasn't indicated by the complaint.

It also means you only chart "pertinent negatives", in other words, only negative findings that relate to the chief complaint. So if someone called for elbow pain, you wouldn't bother charting heart tones. A pertinent negative in that case might be "no tingling or pain in fingers".

 

[teedubbyaw]

SOAP is nice, but by the time you truly document all of the in-depth details, it becomes a lot more than just SOAP format. I can write a pretty good SOAP, but always like seeing how other people document things and get ideas there.

 

[Ewok Jerky]

I also didnt really like SOAP until I got into PA school. I think part of it is with stupid EPCRs there is not much opportunity to free-text, and by the time you get to the narrative, you've already put all the info in once, so why waste time charting it in narrative form? That being said, a complete SOAP note is much easier to read, and is kind of the standard format for the rest of medicine.

Subjective- what the Pt tells you. CC, HPI, OPQRST, all that stuff. Just right down what they said and the answers to any questions you asked them. Any relevant medical Hx, surgical Hx, meds, allergies, risk factors.

Objective- Facts. Start with vitals. I never learned Review Of Systems as an EMT, but that belongs here to. Then your physical assessment. If you've already checked all the boxes on your PCR, then just include pertinent +/-s. Also any relevant diagnotics or labs. Maybe a 12-lead, or lab report from SNF.

Assessment- what is wrong with the Pt. Its OK to list a differential Dx, or just symptoms, or problems. If they have chest pain you can write "possible MI", or "chest pain", or "Suspect STEMI, unsatble angina, GERD, PE, aortic dissection, PNA, anxiety". Its YOUR assessment of what is wrong. Oh yeah, it could also be two things so list whatever you want.

Plan- what are you going to do about the things you just said are/could be wrong with your Pt? This includes interventions, treatment decision, transport decisions.

 

[TransportJockey]

Oh. Just a verbal handoff then?

We also leave s field notes form. Once I get my *** out of bed and down to the truck I'll upload a picture...

 

[Bearamedic]

I usually include one sentence that explains what im dispatched to, and how i got to it.

Then a list of relevant history or major history. (DM, Splenectomy, meds, etc)

What current things i see or relevently do not see and what patient tells me,

What things i do and their outcomes.

 

[TransportJockey]

This is our field form. One carbon copy (yellow) that gets left at the ED

 

[OnceAnEMT]

I've never seen any more than a verbal report in our ED. Sometimes a list of medications or allergies or laundry list of medical Hx, but no specific "handoff report".

I think SOAP is useful concept, but it is simply too generic if used by itself.

 

[Drax]

I've never seen any more than a verbal report in our ED. Sometimes a list of medications or allergies or laundry list of medical Hx, but no specific "handoff report".

I think SOAP is useful concept, but it is simply too generic if used by itself.

If you included SAMPLE+OPQRST for the S of SOAP, what else do you think would need to be included (besides vitals)?