onecrazykid108
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For class we need to do a documentation and we use the format SOAP. Subjective, Objective, Assessment, and plan.
Where would I put Vitals?
Where would I put Vitals?
For class we need to do a documentation and we use the format SOAP. Subjective, Objective, Assessment, and plan.
Where would I put Vitals?
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).
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 =)