SOAP documentation question

[onecrazykid108]

For class we need to do a documentation and we use the format SOAP. Subjective, Objective, Assessment, and plan.

Where would I put Vitals?

 

[medichopeful]

For class we need to do a documentation and we use the format SOAP. Subjective, Objective, Assessment, and plan.

Where would I put Vitals?

Usually, a report will have a special place for vitals. If it doesn't, put them under O (Objective).

This might be helpful:
http://www.geneseefiredept.com/soap.pdf

 

[mycrofft]

Objective

SUBJECTIVE: the subject says.
OBJECTIVE: your recording of vitals and other objective (verifiable quantitative/qualitative) data.
ASSESSMENT: what conclusion does the data lead you to, or do you have an assessment?
PLAN: go to your protocols

 

[Aprz]

A more detail version of what mycrofft said can be found at theemtspot.com. I like what it says.

In short, I would say vitals would go under objective. It's not subjective, something the patient is telling you. It's not assessment, not what your prognosis/diagnosis (we can't diagnosis, but I agree with the author that it's okay to just say what we think it is and what we treated for) of it is, and it's not the plan (what treatment you did).

 

[onecrazykid108]

So is this an ok report using SOAP?
86 YO W/M approximately Kg 100 C/C cp found ambulatory symptoms include none Allergies include milk and water medication includes none Hostory includes died in Vietnam Last oral intake includes coke events include mowing the lawn onset was fast palliation was sitting down quality is sharp Call was MVC

Pt denies back pain, Pt states "but i'm not dead yet, its just a flesh wound", Scene smells like gas, Pt smells like gas and smoke, Pt vitals include Pulse 84 R/R 14 BP 134/96, Vehicle has sever damage, Pt asked to take a toy to the hospital, Pt states "That toy is my life"

Crazy with CP

SAMPLE and OPQRST gathered from decapitated wife, PT was was put on O2 then he suddenly became fine.

Any suggestions or advice is much appriciated.
Thanks =)

 

[medichopeful]

A more detail version of what mycrofft said can be found at theemtspot.com. I like what it says.

In short, I would say vitals would go under objective. It's not subjective, something the patient is telling you. It's not assessment, not what your prognosis/diagnosis (we can't diagnosis, but I agree with the author that it's okay to just say what we think it is and what we treated for) of it is, and it's not the plan (what treatment you did).

Just to jump in on this, if you can scientifically verify/show in some other way that something is there or actually happened, it is objective.

Think of it as the difference between signs and symptoms. A sign is something that anybody can see. I can look at somebody and say "your arm is messed up." Since I can see it, it would go under objective.

The subjective section is like a symptom. You can't look at somebody and say "You're nauseous." Only the PATIENT can tell you that. For the subjective section, it's stuff that the patient (and sometimes bystanders, etc) tell you.

Not a great analogy, but I hope it helps a little bit.

 

[medichopeful]

So is this an ok report using SOAP?
86 YO W/M approximately Kg 100 C/C cp found ambulatory symptoms include none Allergies include milk and water medication includes none Hostory includes died in Vietnam Last oral intake includes coke events include mowing the lawn onset was fast palliation was sitting down quality is sharp Call was MVC

Pt denies back pain, Pt states "but i'm not dead yet, its just a flesh wound", Scene smells like gas, Pt smells like gas and smoke, Pt vitals include Pulse 84 R/R 14 BP 134/96, Vehicle has sever damage, Pt asked to take a toy to the hospital, Pt states "That toy is my life"

Crazy with CP

SAMPLE and OPQRST gathered from decapitated wife, PT was was put on O2 then he suddenly became fine.

Any suggestions or advice is much appriciated.
Thanks =)

Besides the fact that "crazy" is not a legitimate term, looks good! :wacko:

I know you're only joking, but I thought I'd say this anyway: any run-sheet/report you do CAN be called into court. If you don't put something onto the sheet, it didn't happen. Similarly, if there are any obvious grammatical/spelling errs*, it comes across as unprofessional. Write every sheet as if it WILL be called into question in a court.

If you want an example of a SOAP report just let me know and I'll either type one up or find one online.

By the way, don't take this as an attack on you. I know you're just kidding around lol. I just thought it would be a good jumping off point for my little rant :glare:

*see what I did there?

 

[JPINFV]

Classic SOAP setup


Subjective:

C/C
History of present illness (OPQRST)
Past medical history
Past surgical history
Allergies
Medications
Socal history (alcohol, drugs, tobacco, sexual history, work, as appropriate)
Family history (as appropriate)
Review of systems (the questions you ask) divided by system (general, Head/Ears/Eyes/Nose/Throat (HEENT), Neck, Cardio, resp, abd, reprodcutive, extremities, psych, neuro)

Objective

V/S followed by same break down as ROS.

Lab values (if applicable)


Assessment:

Working DX, differential DXs that you are considering (especially if it impacts treatment)

Plan: Treatment plan

 

[onecrazykid108]

Thanks everyone