WHAT is SOAP and CHART??
They are two narritive styles. There are good and bad examples of each. Now below it is going to sound like I think anyone who doesnt write SOAP is wrong, or a bad medic, or something..not the case..Write a good chart, and if it works for you then it works for you. But here is my method, my version of SOAP, and what we use here in Boise.
S- Subjective, in other words what your told and what you read in previous charts. Includes primary and secondary complaints, pert. negatives, OPQRST, SAMPLE, etc.
Example:
Pt is a (adult) y/o male with complaint of general non-specific left side “Aches and Pains” post MVC. Pt reports he was a fully restrained driver in a vehicle (older large sized sedan) that the accelerator apparently stuck on, reportedly causing the pt to lose control in a curve and slide into a vehicle. Impact was to the left side of the vehicle. Estimated speed is 35-40 MPH, no LOC, positive ambulatory post MVC. No neck or back pain, no nausea/ vomiting, numbness/tingling, chest pain, abd pain, or other priority s/s.
Pt denies any recreational drug or alcohol use
O- THis is what you personally see and assess. Traditionally your head to toe, in EMS this extends to scene survey assessments like height of tree they fell from or vehicular damage. Also includes all "Diagnostics" like an EKG or a Blood Sugar.
Example:
GENERAL: Adult male sitting in passenger side of a vehicle, attended by QRU.
VEHICLE: Older Cadillac, full sized sedan, with a single impact noted on drivers side of vehicle. Impact is just being of the drivers B post, with no intrusion into pt compartment nor any intrusion onto the pt. Glass window next to driver seat is intact. Steering column, dash, and windshield is intact.
PRIMARY: LOC: CA&Ox3, calm cooperative. A: Clear B: non labored C: Skin PWD, no cyanosis. D: Moves all ext well, no deficits. Speech is clear.
SECONDARY: HEENT: Atraumatic. Glasses (which pt was wearing at time of impact) are intact with no visible damage. Tongue intact. Bite even. PERRLA. NECK/BACK: Non tender, stable, no deformity. Full spontaneous ROM of neck noted. CHEST: stable non tender Lungs CTA bilat ABD: soft & supple, non tender . EXT: Atraumatic. No localized tenderness. Full ROM, strength, flexion/extension/rotation and sensation, as well as distal pulses to upper ext noted.
SAO2: 98% on RA
A- Assessment, what we call a working field diagnosis. and yes, its OK to do this. Nursing personnel do , so do we. So do all of the medical profession, Its not practicing medicine with out a license, its doing you job. NOTE: The sum of your S and O should meet up with this. For example you cant put down heart attract unless you document the pt is having some sort of heart attack sighs or symptoms. Example:
Non-specific pain post MVC. No specific injuries identified.
P- A narrative description from pt contact to end of call in wich you document in chronlological order everything that happened in itemized format. example:
-Contact, assessment as noted, spinal precautions deferred per protocol, v/s obtained.
-MD eval recommended post MVC, pt elects for EMS transport to (local hospital.
-Pt assisted to MICU for uneventful sit up transport to (Local Hospital).
-V/S as noted. No change in route.
-On arrival pt, backpack with undisclosed contents at ER with full report to staff RN. EMS clear. Pt completes HIPAA Paperwork.
Here is CHART:
C: Chief Complaint
H-History
A- Assessment findings
R- RX as in treatment given
T- Transport events
First of all, the repetition of information between the various fields. Secondly, it doesn't logically follow your treatment. For example, you document in the S section that PT c/o LT arm pain, in the O section PT had obvious deformity and abrasion injury to LT arm, in the A section PT had possible broken arm with soft tissue injury, and in the P section Bandaged and splinted LT arm in place.
Hmm, I have heard the repetitive information complaint before, I just don’t by into it. Simply put, It is important both what you see and what you are told, even if it is the same. For example..if a pt (or a care provider talking about the pt) tells you they have pneumonia (which you put in subjective), do you not document lung sounds (in the objective) that confirm this? Do you put in your assessment "Pt states he has Pneumonia"? Nope, you put "Probable Pneumonia" or something similar.
If a pt states he has had " A bunch to drink" you document that right (in subjective)? Is it considered redundant to document the "strong odor consitant with alcoholic beverage noted at 5 feet when approaching the pt"(in objective)?
Or how’s this: The pt tells you he thinks the vehicle rolled several times, a clearly subjective statement. Do you not document in your scene survey (an objective finding)that the vehicle has damage to sides and roof consistent with a rollover?
Each section in SOAP stands by it self. Therefore while there is some overlap, it is complementary. Think of it like a criminal investigation, it is important what you are told, it is also important what you see, and the differences or similarities between the two are important as well. Like two different witnesses , MR. S and MR. O telling their own version of what happened, and with out one or the other telling his complete story, then you dont get the complete picture.
Now your probably saying…..yeah yeah , that’s what Im complaining about. OK, so its a little more work, but in my very humble opinion it makes for a great chart, easily read and easily deciphered, and it is consistent with much of the rest of the medical community.
"I asked why the SOAP format was required, and was told so that the hospital can look up specific information when needed. I agree that a standard format is nice, but shouldn't they be reading the whole report instead of bits and pieces? "
Your right, and they frequently do, but its hard (I know, from a QA point of view) to pick apart vital components for analysis with a format that is haphazard or with which you are not familiar. Think of it this way, you don’t write down word for word everything a pt, bystanders, dispatch everyone says, right? No you organize and summarize so as to better paint a picture. And that is likely what the hospital means, they want something they can assimilate quickly, and SOAP allows that.
And not to sound arrogant, Ill put my SOAP up in court anyday.
)