Part 1: Pre-SOAPeD
I’m back! Sorry for the neglect of the blog, but between surviving the Respiratory final, Christmas, and then surviving the Reproduction midterm left me with little time to actually, you know, write posts.
Continuing on the theme of, “Why didn’t they teach me this as an EMT?” line, I’m going to touch on documentation next. Knowing what I knew now, if I ever went back to work as an EMT I’d use a system I’ve termed “Pre-SOAPeD” to organize my “narrative” for emergency calls. I place “narrative” in quotes because, when used properly, it’s really much more than a narrative. It’s more of the entire run sheet in story form. The format itself is the standard SOAP format with two extra categories to it, prearrival, and “Delta” (delta being the medical symbol for “change”).
Now, I’m going to get on my soapbox for a minute and say that the way most people teach SOAP narratives are wrong. A lot of people like to mess around with what goes into each section, especially the “assessment” section (normally people who like to repeat the cliché of “we don’t diagnosis” as justification), but the most common change is the actual format. Unfortunately, changing the format also destroys one of the biggest benefits of the SOAP format, an easy to follow standardized format. Next time you do an interfacility call (be it a hospital discharge, critical care transport, nursing home to emergency department, doctor’s office to someplace) take a look in the packet. Chances are, regardless of where the physician went to school, there will be a history and physical in the packet that will have almost exactly the same formatting as every other history and physical. That’s not a coincidence. There are reasons for this that goes beyond making sure the right things are documented. If everyone is using the same format, then you know exactly where to look to get information. All of a sudden that 5 page H&P on the nursing home patient with 200 different diseases becomes a lot easier to read because you know where you need to look for the information you want.
The format that I would use looks like this:
- History of Present Illness
- Medical History
- Surgical History
- Family History
- Social History
- Review of systems
- Head, Ears, Eyes, Nose, Throat (HEENT)
- Vital Signs
- Lab Values (SpO2, EKG, BGL, etc)
- Delta (“change,” or response to treatment)
The way that this is presented, in bullet form, is really the way it should be presented. If you can’t easily find the abdominal section of the review of systems because it’s flanked by other systems in a paragraph format, then you lose the benefit of quickly being able to find specific information. However, as we’ll see, the formatting is the only part of this that is really inflexible. Unfortunately, the only problem is that this style tends to also eat up more room, which I’ll provide a solution for later.
Over the next week or so, I’ll take you through each separate section and also discuss some of the advantages, limitations, and work arounds for this system given the nature of EMS documentation.
PS: For the grammar purists, “Respiratory” and “Reproduction” are the actual course titles, hence the capitalization.