SOAP
Or, How to Write a Clean Run Report
(pun intended)
S- Subjective
This is where you paint your picture.
• Chief Complaint/ Mechanism of Injury
• OPQRST (Retrosternal chest pain, onset at
rest, rated 5/10, dull and radiates to left arm
and jaw and nausea)
• Past Medical History (HTN, COPD, Angina,
etc.)
• Patient states,”It hurts when I pee.” (Quotes
are good.)
Subjective (cont.)
• Don’t forget to write if the patient is SNF
• -and/or- Meets the definition for bed
confinement
• -and/or- Could go by other means but you
explained the NEMB form (and they signed
it).
• This could also be charted at the end of the
narrative (after “P”).
O- Objective
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Your Assessment and Findings
Primary and Secondary survey results.
Head to toe positive and negative findings.
AVPU, Airway, Head/neck, Chest,
Abdomen, Back, Extremities, Neuro, GU,
cardiac monitor, O2 Sat, BGL, etc.
DO NOT RELY ON THE PROGRAM’S
ASSESSMENT FEATURE. It’ll bite ya!
“Exam Normal” or “WNL” does
not tell the court anything about
what you saw or assessed.
Heck, it doesn’t even tell a lawyer
if you actually assessed anything.
Do you expect a lawyer (or Medicare) to
believe you when you tell them you
looked at their client’s belly after writing
“Exam normal”?
A- Assessment
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•
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Your Field Diagnosis/Suspected problem(s)
such as: Hypoglycemia
-or- 1) Hypotension, 2)Bradycardia
-or- Chest Pain secondary to Bradycardia
-or even- M.I. with ST elevation in Inferior
leads.
P- Plan
What you did, in order that you did them (if
possible).
• Moved patient to stretcher and placed
patient in POC (semifowler’s), O2 NC @
4LPM, Vitals, 324mg ASA PO, Cardiac
Monitor, 18ga IV Left AC, NS at KVO with
100cc’s infused, 12 Lead, 0.4mg NTG SL x
2 with complete relief of pain, reassess,
reassure, turn care over to RN with report
given, PCS form signed by Dr. No.
Plan (cont.)
• Remember to document if a therapy helped
or made no change in patient condition
(such as results of Fentanyl, NTG, etc.).
You are CQI
What would you add or subtract?
Note: If you recognize the narrative as yours,
don’t be afraid. CQI is a learning process. It’s
when the same or similar issue is addressed time
and again when management will step in.
Narrative #1
S - Called to the home of a 40 y.o. female with a CC of side pain. Pt states she
passed out, without a fall or any trauma. Pt CAOX3 UOA and sitting in a chair.
Pt states her husband came home to take her to the hospital. PMH Hypotn,
Asthma, Gastric BP, Anxiety, Panic Attacks, R Foot Surgery, and currently being
evaluated for Gall Bladder and Ulcer problems.
Meds ansd allergies as stated. No other c/o pain or discomfort. Medical Control
via Dr. David Bachman of CMMC for fentanyl and promethazine as given below.
O - Vitals below. +PE with pain on plap of right side, rest of PE = WNL. EKG
and 12 Lead are NSR throughout Transport. BG = 108. LS clear Bilaterally.
Assess pt, Spinal Assessment, IV, Med Control, Meds Reassess, Transport,
Document.
Questions?
• Where was the pain? Which side? Quality?
Quantity? How long? Radiation?
• If no fall or trauma, why the spinal
assessment?
• Why the meds? Did the meds work?
• 12 Lead or cardiac monitor? She got meds
and she passed out.
• Blood Glucose Analysis?
• Anything else???
Runsheet #2
[S] Called to {town/street removed for privacy}for a female who fell.
HPI- female pt fell while walking along her deck. Board gave way and pt
fell through the floor. Female denied any LOC neck or back pain. Pt was
splinted upon our arrival.
O female pt seated on couch. a- clear, b- unlabored, c = raqdial pulses
heent -wnl neck - wnk chest - wnl. abd -wnl, legs- left ancle pain
splinted prior to arrival. arms - right wrist pain. unable to get bp due to pt
size and noise.
[A] sprain / fracture right wrist left ancle
{p} assessment, vitals, stairchair outside, to cot, transport poc, no changes
enroute, pt moved via slipp to bed at Er .
Questions?
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Spelling. Spell check is available, use it!
Spinal assessment done? By who?
Who splinted PTA?
Pain on scale? Does she bear weight?
Swelling, deformity, (-) CMS?
IV? Meds? If not, did they refuse them?
Unable to get up due to noise???
Runsheet #3
Called to SRNCC for an elderly male patient that had fallen and is
complaining of hip pain. Nursing staff state patient had fallen in the
bathroom this morning and is now complaining of back,neck and hip pain.
Nursing staff state 'this is normal level of consciousness and breathing for
this patient. Staff state patient scheduled for a neb treatment @ 0700 this
morning so he hasn't had any of his meds yet. Patient states over and over
'Oh God, and I hurt'. Patient unable to apply a numerical value to the pain.
PMH: dementia, chronic airway obstruction, depressive disorder.
Upon our arrival we found a 87 year old male patient complaining of neck,
back and hip pain. No obvious deformity was noted on exam. No DCAPBTLS noted on exam, abdomen soft nontender.Cervical collar was applied,
patient moved to longboard,oxygen applied ,oxygen saturation originally
@ 88% increased to 95%. Limited secondary assessment due to short
transport time. Patient care turned over to FMH ED staff without incident
or further change.
Questions?
• Not in SOAP format (not always a bad thing
so long as the info is there).
• Any mention of C-collar or HID?
• Anything else? (pretty good sheet IMHO)
Questions?
Don’t hesitate to contact Cory
(491-1015 or cmorse@fchn.org),
Tom (897-3611), or Wade (2352228) if you need any help.