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SOAP – Not just for your hindquarters anymore Part 2

July 30

Yesterday we dove into the S – Subjective potion of the SOAP narrative, today we’ll move on to the O – Objective. This is the section of the narrative where you both document your examination of the patient AND what you found. For our young trauma patient we will have our rapid trauma survey, initial assessment from head to toe, secondary assessment as well as any changes we discover on subsequent exams. An important point to note here – in the first post of this series we talked about the fact that if it isn’t written down it wasn’t done, this is especially important in this section. Often many of us will fail to put the areas where we didn’t find anything pertinent into our objective section. We know that we checked the areas that aren’t listed there BUT someone picking up our PCR later that wasn’t on scene with us has no idea why it isn’t there. So list the results of your head to toe assessment – even if they offer no clue as to why your patient called 911.

I like to separate my initial findings from my secondary exam/response to treatment findings, but to the best of my knowledge there is no hard and fast rule about how this should be documented, form isn’t necessarily the most important aspect here – documenting what you did and what you found is.  A lot of providers out I have worked with will type their sections as one long paragraph – while this is acceptable (provided everything is in there) let’s pretend you are the ED doc who is going to look at the report – do you want to have to scan through the entire paragraph when all you need is three words buried in the middle, or would it be easier and more efficient for you to be able to look for findings related to your patients chest and pick them out instantly? No brainer right? We all bitch that our reports aren’t read and use that as an excuse to do a sloppy and incomplete job – it doesn’t have to be that way. If you want your reports read/used write them in a way that they are ACTUALLY readable/useable.

Just like yesterday, actual narrative is bold – comments are in normal font. At the end of today’s entry, I’ve included yesterday’s S section along with today’s O so we can begin to see the whole narrative in one place

NARRATIVE (Continued)

O: Findings on initial examination

Airway: Open and patent

Breathing: Rapid w/ poor movement

Circulation: rapid radial pulse, minor bleeding from scalp lac, no major bleeding found

Skin: Pale, Cool, diaphoretic, cyanosis noted around lips

LOC: confused and abusive, won’t follow commands

Head: Blood in hair, no active bleeding, no other wounds noted, PERRL

Neck: No DCAP/BTLS noted, possible tracheal deviation to the right, positive JVD

Chest: Contusions noted to left chest, no paradoxical movement, crepitus and tenderness on palpation, breath sounds absent on left

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

Upper legs: Swelling, tenderness, deformity of left upper leg, normal CMS

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

Initial vitals: 90/50, pulse 150, respirations 36

GCS: 13 (eyes – 4, verbal -4, motor -5)

Cardiac Monitor – 3 lead – Sinus Tach

Sensory and motor function: normal

At this point we have completed our “rapid trauma survey” and would make the decision that this is a “load and go” patient. There are some interventions that would have occurred during this portion of the survey: (needle decompression, ventilatory assistance, spinal motion restriction, etc) – however this section is about our findings not what we did – you will see the effects of those interventions on further exam but we won’t spell out in detail what we did until we get to the P section.

SECONDARY SURVEY: performed after initial interventions – en route to hospital

Airway: patent

Breathing: improved movement of air, less work to breathe, breath sounds now present on the left although diminished

Circulation: no major bleeding noted

Skin: pale, cool, diaphoretic, cyanosis around lips is improved

Vitals: 100/60, pulse 110, respirations 30

Cardiac Monitor – 12 lead – Sinus Tach

LOC: unchanged

GCS: unchanged

BGL: 40

Head: blood in hair from approx 4″ long scalp lac, no active bleeding, no battle sign or raccoon eyes, no drainage from ears or nose, face is atraumatic, PERRL

Neck: trachea appears more mid-line, JVD is no longer present – No DCAP/BTLS

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

Lower extremities: Left leg in traction splint – CMS present, right leg no injuries noted

We have now completed our detailed head to toe survey, we have an idea that the interventions we initially provided for our patient are helping, and we identified another area that requires our attention, from this point forward we have identified all obvious injuries/concerns with this patient that we will be able to find in an EMS setting, subsequent exams/documentation need to focus on continued exam of problem areas and any improved/worsening conditions we find.

ONGOING EXAM: Performed after secondary interventions

BGL: 80

LOC: Patient is awake and alert, less combative and able to follow commands

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Cardiac Monitor:  unchanged

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

Unless you have an ungodly long transport time (in which case I hope you considered a chopper for this guy) if you get this much exam done you are doing fantastic – but this should give you an idea of how to document initial, secondary and focused findings on a patient who has several critical injuries. Now I’ve removed the comments and put the whole objective section after the Subjective section – if you put the two of them together you should be able to figure out what will appear in the A and P section as these are all based on the sections we have already completed, if at this point you can’t figure out what’s wrong with this patient either I didn’t document it properly or you need to review trauma 😉

Notice how easy it is to find what you are looking for when everything is separated into its own line and listed in the order of examination.

NARRATIVE

Ambulance 123 and engine 456 dispatched emergent to go fast speedway at 123 any street for an auto-ped MVC

U/A found approx 20 YO M pt lying next to the race track in a semi prone position. Patient’s c-spine is being held by track employee and two other track employees are talking to the patient. Patient’s pants have a large tear in them in the left upper leg region and the left leg is bent at an awkward angle. Blood is visible in the patient’s hair and the patient appears very pale.

S: Pt is a 23 YO M. Patient states he “Can’t breathe” and his “chest and leg hurt”. Patient speaks in one to two word sentences and is confused and disoriented. Patient states that “a car drove right over me!” Patient states he isn’t sure how long ago this occurred.

HEENT: no complaints – pt states he “thinks he feels blood running down his face, but it could be sweat”

Chest: pt C/O pain to left chest – Pt denies having this pain before the collision, breathing/moving makes it hurt worse, pain is described as being sharp and squeezing at the same time, patient denies any radiation, pt rates the pain a 10

Back: no complaints

Abdomen: Pt C/O pain on palpation, patient denies any pain before accident, “you pushing on it” makes it worse, pain is described as dull all over his abdomen with no specific site, patient denies any radiation, patient rates the pain a 6

Pelvis: no complaints

Lower extremities: Pain to Left upper leg, patient denies having any pain before the accident, trying to move it makes it worse, pain is described as sharp and pulsating, patient denies any radiation, and rates the pain as a “12″

Upper extremities: no complaints

Allergy to PCN

Medications: insulin

PMHx: DM 2

Patient does not remember the last time he ate.

Patient also states he has a headache and some dizziness. Patient denies N/V/D as well as any LOC, but says he isn’t sure about that.

Bystanders give verbal report as follows: patient was walking from the pit area when he was struck by a vehicle traveling at a high rate of speed. Bystanders say that car did in fact drive over the patient saying he collapsed on impact and went under the car. Bystanders add that the patient was unconscious until just prior to our arrival. Bystanders also report that patient has not been moved and that track personnel were to him almost immediately keeping him still and “holding his head”.

O:

INITIAL EXAM

Airway: Open and patent

Breathing: Rapid w/ poor movement

Circulation: rapid radial pulse, minor bleeding from scalp lac, no major bleeding found

Skin: Pale, Cool, diaphoretic, cyanosis noted around lips

LOC: confused and abusive, won’t follow commands

Head: Blood in hair, no active bleeding, no other wounds noted, PERRL

Neck: No DCAP/BTLS noted, possible tracheal deviation to the right, positive JVD

Chest: Contusions noted to left chest, no paradoxical movement, crepitus and tenderness on palpation, breath sounds absent on left

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

Upper legs: Swelling, tenderness, deformity of left upper leg, normal CMS

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

Initial vitals: 90/50, pulse 150, respirations 36

GCS: 13 (eyes – 4, verbal -4, motor -5)

Sensory and motor function: normal

SECONDARY SURVEY: performed after initial interventions – en route to hospital

Airway: patent

Breathing: improved movement of air, less work to breathe, breath sounds now present on the left although diminished

Circulation: no major bleeding noted

Skin: pale, cool, diaphoretic, cyanosis around lips is improved

Vitals: 100/60, pulse 110, respirations 30

LOC: unchanged

GCS: unchanged

BGL: 40

Head: blood in hair from approx 4″ long scalp lac, no active bleeding, no battle sign or raccoon eyes, no drainage from ears or nose, face is atraumatic, PERRL

Neck: trachea appears more mid-line, JVD is no longer present – No DCAP/BTLS

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

Lower extremities: Left leg in traction splint – CMS present, right leg no injuries noted

ONGOING EXAM: Performed after secondary interventions

BGL: 80

LOC: Patient is awake and alert, less combative and able to follow commands

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

 

Posted by on July 30, 2011 in documetation, EMS, legal, Paramedic School

1 Comment

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One response to “SOAP – Not just for your hindquarters anymore Part 2

  1. shadez2270

    August 1, 2011 at 15:11

    THANK YOU for your suggestions and assistance with the “over my paygrade” Tx stuff C.J. I appreciate it!

     

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