Trying to figure out SOAP

[IrishManiac316]

So I'm in need of some assistance. In my class we have to use the Soap PCR format (I understand CHART more) and I can't seem to figure it out. The more I try to figure it out the more it confuses the living hell out of me.

Can some one try to help me out, I only have a little bit before I'm out of class and i need 10 SOAP PCR's to pass!

 

[NomadicMedic]

Think of it this way.

S is for subjective. That’s everything they tell you. Everything the patient says, everything the wife says, everything the bystander says, everything that you didn’t directly see here smell or touch.

O is for objective. Everything you saw smell touched tasted… Everything that you observed.

A is for assessment. All the things that you discovered during your assessment.

P is for plan. Treatments you performed, patient condition during the transport. Where are you went and how you got there.


I usually write my charts in a modified soap form which is more chronological. Something like this

Medic 6 was dispatched to the above address for a priority chest pain call. The unit responded from the station with lights and sirens and arrived on location without incident.

On arrival, I was met at the front door by the patient’s wife. She related that her husband had fallen to the floor and was complaining of chest pain and shortness of breath. She said she had been complaining of nausea about 20 minutes prior and he took a Tums.

When I made patient contact I observed a 50-year-old male lying on the floor in the kitchen complaining of 10 out of 10 chest pain. He described it is crushing and located sub sternal he. Nothing he did made it better or worse. He related to chest pain started about 15 minutes before he called 911. He related he’s never had any incident like this before. He denies any cardiac history or any other significant medical history. His only medication is the occasional an acid and daily vitamin. He denies any allergies

I immediately assessed patient for immediate life threats, and found none. The patient presented with a patent airway. He was breathing shallow and rapidly. SPO2 was 92% on room air. Patient was placed on 4 L of oxygen via nasal cannula. Skin was cool and diaphoretic. His radial pulse was rapid. A 12 lead was quickly captured showing a inferior STEMI with ST elevation in leads II, III and AVF. Vital signs were obtained and are listed in the timeline. 12 lead ECG was transmitted to the hospital per protocol. IV access was obtained in the right AC with an 18 gauge catheter and 500 mL of NSS was infused. Patient received 324 mg of aspirin PO. Patient refused any analgesic.

Patient was quickly moved to the ambulance litter and secured with five straps and rails up for movement to the ambulance. A transport to the local hospital was started emergently. Medical command contact to advise a STEMI alert.

The patient was monitored continuously for changes during transport, there were none of significance. Upon arrival the patient was moved to ER room one and the cardiologist met the crew at bedside. Patient was moved to bed via IV person she left and report was given to the team at bedside. Patient signed box one of the HIPPA form and a face sheet and all signatures were obtained.

Blah blah blah. It’s not exactly soap, but it covers all of the major points and paints a good chronological picture.

 

[Akulahawk]

The SOAP note is actually not that difficult to understand... though it seems a bit complicated at first. First break the thing down to it's components: S/O/A/P. Each stands for a particular section.

S- Subjective - This is pretty much anything anyone can tell you about the patient. This stuff is all "unmeasurable" because you can't measure it. This includes stuff the patient tells you. I would include pain in this because (for now) we cannot measure pain. If I chop off one of your fingers, I cannot objectively measure the amount of pain you perceive. If there were no witnesses and the patient was completely unresponsive, this section would be quite bare.
O- Objective - This stuff is the measurable, observable, repeatable stuff. Your physical assessment/findings go here, as would vital signs.
A- Assessment - Think of this as a statement of what you think is wrong with the patient. In effect, this is your working diagnosis, based on the stuff you've found in the above, and therefore is what you are treating the patient for.
P- Plan - This is the "how" you intend to treat.

The deeper you get into doing patient assessments further into your education, the above can fill out quite dramatically. The "S" section can include a "review of systems" which details how the patient thinks each body system is doing. The "O" section will eventually have labs, imaging, and so on. The A/P sections therefore become more detailed as they begin to outline problems you've uncovered and how you intend to address each of those.

Why are you being asked to do SOAP notes? Simple: they are found nearly everywhere in healthcare and the better you understand them, the better you'll be able to read them. At all the hospitals I have been to and have been able to read charts of patients I have had care turned over to me, I have read many, many H&P notes and they've all been based on the SOAP note. The exact format may be slightly different, but the basic stuff is there. These notes are ubiquitous, all medical providers understand them. If I didn't have a pre-made template for doing my patient care charting, the SOAP note is how I'd do mine. Yes, they do have their drawbacks, all charting methods do, but at least the SOAP note is universally understood.

 

[ghost02]

I used to have a similar issue, we aren't required to use the SOAP method, but looking at my documentation before and after, it is a huge improvement.

Subjective: I normally introduce the patient "Tbe patient is a 75 year old white male..." then chief complaint in patients words "... complaining of 'chest pressure'". The I do an OPQRST, Past medical, allergies, medications with compliance, real quick social hx if I have time, and a review of systems which you can google for more info.

Objective: What you see and your visual assessment, skin signs work of breathing, relevant vitals, results of physical exam both positive signs such as pedal edema, and pertinent negative signs such as no JVD. If there is relevance to the environment I put it here as well, such as an asthma attack when a home has significant dust or things along those lines.

Assessment: This is what i had the hardest time with. So I would put your differential dx. Such as, "Patient presents consistent with pneumonia considering unilateral upper lobe late inspiratory crackles with productive cough and dyspnea Possible chronic bronchitis exacerbation considering hx of 1 pack a day smoking and unconfirmed dx of COPD. Rule out other pulmonary etiology."

For altered mental with no hx this is where I would go through AEIOU TIPS as those are the primary differential for altered mentation.

Plan: what you're going to do, such as "Obtain Baseline vitals and secure patient to gurney with straps. Initial tx to hospital name per pet request, code 2, without incident. Administer 2lpm oxygen via NC with improvement in Sp02 >94% and significant reduction in complaint of dyspnea. Obtain IV access. Continued cardiac and hemodynamic monitoring during transport. Contact made with MICN with no question or orders. Tx care to staff."

As you do it more and more o think you'll notice your assessments get better and better.