How Do You Document?

[UMSTUDENT]

I'm finishing my last year in school and currently we're focusing heavily on documentation. I was wondering how everyone here documents their ALS calls? Specifically, I'd like to see how you do a review of systems within a SOAP (SOAPIE) format. It is something that many people do, but I've never been instructed on.

I'm just intersted to see how different ALS providers document. Please feel free to give examples.

Thanks.

[fireflightmedic1]

S=Subjective what you are told how the scene looks

O=Objective what you find how you found your pt

A=Assesment v/s ekg

P=treatment and outcome

I personally do not use this i use S A TX O

SUBJective and objective combined and the my assesment my treatment and then outcome if tx it flows like a story from beginning to end.

[fireflightmedic1]

sorry more in deatail

S 8114 disp to the above address on a person down unknown nature. Upon ems arrival Fulton fire and PD onscene. Pt found lying supine on the ground w/what apperars to me vomitus next to him. Per Bystanders on scene "He was ridning his bike and he just fell over and started twitching." Per fire "we found him in an active seizure with blood coming from his mouth. We have attempted and IV no luck yet. He just had stopped seizing" Unknown Hx unknown meds unknown allergies

A approx 31 y/o male found lying on the ground blood coming from mouth. HEENT normocephelic. pupils constricted at 2mm reactive to light. Airway patent resp 18 nl =cr/cf sao2 98%RA Pulse 134 rrr sinus tach on mon. no ectopy. Blood coming from pt's mouth from poss. biting of oral pharyanx. BP 134/86

TX IV NS KVO 18g L AC: 18g INT R AC o2 2lpm via nc transp to closest hosp.

O while enroute pt began to have another seizure gave pt 5mg diazapam IVP per DR Gilts @ SFMC via med radio and Fulton County Seizure protocol. Gave thru L IV Cont V/S CK every 5-10.

EKG NS rate of 100bpm. POst Diazapam pt became post ictal and slowly became A/O x 3

Pt care transported to SFMC w/o incident enroute. Pt care transferrred over to Nurse smith with out incident.

Waste 5 mg diazapam wit. by ____________

Ordered by DR Gilts __________

[UMSTUDENT]

Objective comes before assessment. I'm familiar with SOAP.

[JakeEMTP]

I personally prefer the CHART format. I'm sure you are familiar with this, however just in case you aren't it is as follows,

C - Chief Complaint

H - Hx ( pertinent and past)

A - Assessment

R - Rx ( your treatment and patient response)

T - Transport (transport mode, level of care, destination and significant changes in pt. during transport).

This system works for me. SOAP is also a proven method. Regardless which format you choose, stick with it and it will become second nature to you.

[fireflightmedic1]

which O were you refering? yours in the SOAP or mine at the end. Mine stands for out come post tx but everyone has a different way of writing. My fiance is a CCEMTP and writes like a nursing chart format. And another FP-C paramedic wirtes in the CHART method

any way good luck to you in your class

[mobey]

I do not use soap at all. In fact I'd never heared of it till I came to the city.

I have my own format:

HxCc (history of chief complaint)

PmHx (Past med history)

O/A (On arrival, includes scene info and first impression)

O/E (On exam - Broke into systems as below)

LOC, A&O, A,B,C, Skin, CNS, CVS, Resp, Gi, Gu, Extremeties, MSK.

If it is a trauma

LOC, A&O, A,B,C, Head, Neck, Chest, Abd....and so on.

This way I can write what I don't find as well as what I find. Ya It's alot of writing but I got used to it.

[ccmedoc]

I personally prefer the CHART format. I'm sure you are familiar with this, however just in case you aren't it is as follows,

C - Chief Complaint

H - Hx ( pertinent and past)

A - Assessment

R - Rx ( your treatment and patient response)

T - Transport (transport mode, level of care, destination and significant changes in pt. during transport).

I use this too..quick, concise, and its all there. I never liked SOAP..don't know why. Thats what they push in the hospital, but....... :roll:

[CBEMT]

HPI

PE

TX (most of which can be referred to the Treatment section of the run form)

[HPI] EMS dispatched --> above loc. for "Chest Pain." Pt c/o 5/10 sharp stabbing [L] C/P "all day." (-) radiation, (-) trauma, (+) SOB due to pain. Pt denies n/v/d, h/a, dizziness/lightheadedness, recent travel, or med [changes]. Hx/Rx as noted. Pt compliant w/ meds, took no additional meds prior to EMS arrival. (-)Recent illness, travel, or med [changes]. Last intake- breakfast. [PE] 52 y/o [male] seated in chair, rubbing chest occasionally but otherwise NAD. (-) JVD, trachea midline. Skin warm/dry/pink. Lung sounds- clear bilat. Abd soft/ non-tender. LE's unremarkable, (-) edema. PMS (+) x4. Vitals as noted. ECG- NSR (-) ectopy (-) STEMI. [Tx] Pt -->stairchair-->stretcher--Truck-->ABC ED. Monitor, IV as noted, O2 4 lpm via nc. ASA/NTG as noted. Care/reports t/f -->ABC ED staff [without] incidents. [Changes] as noted.

Time HR R BP Treatment Results/Comments

13:45 90 16 150/90 Vitals, Stairchair, ASA x4 @ 81mg S PO2 98% @ RA

13:55 92 16 148/90 O2, ECG, IV, T/P, NTG x1 SL 1/150 Pain 5/10 -->3/10

14:00 86 16 128/80 Monitor Pt, NTG x1 SL 1/150 Pain 3/10 --> 1/10

14:05 86 16 110/76 Monitor Pt Arrival

Endotracheal Intubation Intravenous Therapy

Tube Size Attempts Gauge Attempts Flow Rate Lines

(-) (-) 18g L AC 1 200cc--> KVO 1

Can't really express the format here but hopefully you get the idea.

[AnthonyM83]

S=Subjective what you are told how the scene looks

O=Objective what you find how you found your pt

A=Assesment v/s ekg

P=treatment and outcome

I personally do not use this i use S A TX O

SUBJective and objective combined and the my assesment my treatment and then outcome if tx it flows like a story from beginning to end.

This seems exactly like what I use. I find it redundant to use O and A...so instead combine. My assessment INCLUDES objective information.