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Old 04-09-2004, 12:44   #1
NousDefionsDoc
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SOAP Notes Rite in the Rain

I think I like this.

Cool Medic Stuff
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Old 04-09-2004, 13:25   #2
Surgicalcric
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SOAP...uggggg.
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Old 04-09-2004, 15:05   #3
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You got something better?
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Somewhere a True Believer is training to kill you. He is training with minimal food or water, in austere conditions, training day and night. The only thing clean on him is his weapon and he made his web gear. He doesn't worry about what workout to do - his ruck weighs what it weighs, his runs end when the enemy stops chasing him. This True Believer is not concerned about 'how hard it is;' he knows either he wins or dies. He doesn't go home at 17:00, he is home.
He knows only The Cause.

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Old 04-09-2004, 16:33   #4
Surgicalcric
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I have something better for EMS specific calls. I do not have one that is a 'one-size fits-all' system similar to that of the SOAP method.

If you are interested I could share it here.
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Old 04-09-2004, 16:40   #5
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Go ahead.
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Somewhere a True Believer is training to kill you. He is training with minimal food or water, in austere conditions, training day and night. The only thing clean on him is his weapon and he made his web gear. He doesn't worry about what workout to do - his ruck weighs what it weighs, his runs end when the enemy stops chasing him. This True Believer is not concerned about 'how hard it is;' he knows either he wins or dies. He doesn't go home at 17:00, he is home.
He knows only The Cause.

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Old 04-09-2004, 16:56   #6
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I would be interested in the EMS specific one myself.



Side Note:
In Medic class today we went over about 10 weeks of Anatomy and Physiology in about 6 hrs. My brain is on overload. I am glad I took that A/P class last quarter to get ready for Medic school. Studying at least 2-3 hrs a night will be a common practice at my house from here on out.

Best Regards,

Jason
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Old 04-09-2004, 18:51   #7
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DX: This section is to tell general details about the patient (age, sex,), why EMS summoned and what PT is being treated/transported for.

1º: Primary Survey - how patient found; A,B,C, & D.

2º: Secondary Survey- Physical findings both Pos & Neg as they relate to complaint; pupils, lung sounds, DCAP/BTLS, EKG, SAO2, ETCO2, etc...

TX: Treatment rendered, facility transported to, personnel PT care transferred to.

Δ: Changes in patient condition pos & neg.

HX: past pertinent medical history, MEDS, allergies, MD’s
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Sample from a recent call

DX: EMS summoned to residence of 54 y/o/w/♂ c/o chest pain w/o relief after SL NTG x 2.

1º: PT found seated upright; A,B,C+; A&O to person, place, time, events.

2º: PT c/o crushing type pain over mediastinum which began while mowing lawn, pain rediating down L arm, Pain 8 on 10 scale, non-reproducible on palm or respiration and began ≈30 min PTA EMS. Pain has not been relieved with ↑self TX. PT also c/o assoc severe SOB. B/P-80/54, Pulse-50/irreg, Resp-24/labored. PERRL, L/S-Rhonchi bilaterally w/ = mvmt, SAO2-88% on RA, ETCO2-32mmHg. LP-12 showing SB @ 48-54 BPM with frequent PVC’s non-perfusing. 12-lead showing acute inferio-septal MI.

TX: O2 NRB at 15-lpm, IV L hand/18ga NS KVO, IV R hand/18ga NS @ KVO. NTG .04mg SL(RPT x2@ 5min intervals), MS 5mg IVP (RPTx1 @ 10 min), Lasix 100mg IVP, Dopamine drip titrated @ 400mcg/min, T-PA 10mg IVP over 2min/ drip at 50mg/hr, –>F/W–>M-106. T-port Code3 to GMH ER. Oral report enroute to MCD-12. Transferred to bed CC#4 and left ICO RN and MD @ bedside after report given.

Δ: SAO2-↑94% with O2, B/P-↑98/64, Pt states no relief of pain but some relief of SOB, no change w/ follow on 12-lead.

HX: MD-Cano, NKDA, MEDS: NTG, PMH: Angina.
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Old 04-09-2004, 18:55   #8
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Crip, that's a SOAP note without the easy to remember pnuemonic.
DX1o2oTXAHX doesn't spell anything.
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Somewhere a True Believer is training to kill you. He is training with minimal food or water, in austere conditions, training day and night. The only thing clean on him is his weapon and he made his web gear. He doesn't worry about what workout to do - his ruck weighs what it weighs, his runs end when the enemy stops chasing him. This True Believer is not concerned about 'how hard it is;' he knows either he wins or dies. He doesn't go home at 17:00, he is home.
He knows only The Cause.

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Old 04-09-2004, 18:58   #9
Surgicalcric
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SOAP just repeats itself...

I did not say our method here was a nifty acronym. I like the CHART method as well.

Now, if you will excuse me I need to take a few pics of my FUGLY mk-III on my Marauder for posting purposes.
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Old 04-09-2004, 18:59   #10
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What do you mean repeats itself?
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Somewhere a True Believer is training to kill you. He is training with minimal food or water, in austere conditions, training day and night. The only thing clean on him is his weapon and he made his web gear. He doesn't worry about what workout to do - his ruck weighs what it weighs, his runs end when the enemy stops chasing him. This True Believer is not concerned about 'how hard it is;' he knows either he wins or dies. He doesn't go home at 17:00, he is home.
He knows only The Cause.

Still want to quit?
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Old 04-09-2004, 19:07   #11
Surgicalcric
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I find most people cant tell the difference between the S and O. They tend to repeat themsleves.

There is also an Evaluate on the end now.

Did you learn the SOAP method as a part of your MOS training?
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Last edited by Surgicalcric; 04-09-2004 at 19:10.
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Old 04-09-2004, 19:09   #12
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Well, not being able to write them correctly hardly invalidates the system.

What's CHART?
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Somewhere a True Believer is training to kill you. He is training with minimal food or water, in austere conditions, training day and night. The only thing clean on him is his weapon and he made his web gear. He doesn't worry about what workout to do - his ruck weighs what it weighs, his runs end when the enemy stops chasing him. This True Believer is not concerned about 'how hard it is;' he knows either he wins or dies. He doesn't go home at 17:00, he is home.
He knows only The Cause.

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Old 04-09-2004, 19:34   #13
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Quote:
Originally posted by NousDefionsDoc
Well, not being able to write them correctly hardly invalidates the system.
I was waiting for that..
Tee Hee Hee

Eagle
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"I have hung out in dangerous places a lot over the years, from combat zones to biker bars, and it is the weak, the unaware, or those looking for it, that usually find trouble.

Ain't no one getting out of this world alive. All you can do is try to have some choice in the way you go. Prepare yourself (and your affairs), and when your number is up, die on your feet fighting rather than on your knees. And make the SOBs pay dearly."
The Reaper-3 Sep 04
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Old 04-09-2004, 20:05   #14
Surgicalcric
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I did not say the system was invalid did I?
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"It's better to die on your feet than live on your knees."

"Its not who I am underneath, but what I do that defines me" -Batman

"There are no obstacles, only opportunities for excellence."- NousDefionsDoc
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Old 04-09-2004, 21:52   #15
NousDefionsDoc
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Quote:
Originally posted by Surgicalcric
I did not say the system was invalid did I?
No, no you didn't.

Quote:
SOAP...uggggg.
Quote:
SOAP just repeats itself...
My bad, sorry. Carry on. At ease, all that Army stuff.
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Somewhere a True Believer is training to kill you. He is training with minimal food or water, in austere conditions, training day and night. The only thing clean on him is his weapon and he made his web gear. He doesn't worry about what workout to do - his ruck weighs what it weighs, his runs end when the enemy stops chasing him. This True Believer is not concerned about 'how hard it is;' he knows either he wins or dies. He doesn't go home at 17:00, he is home.
He knows only The Cause.

Still want to quit?
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