EMS Documentation: Introducing Pre-SOAPeD
As I mentioned in the opening, one of the big advantages of a SOAP note is the fact that it’s essentially the standard form of documentation in medicine. However, I won’t argue that there are certain operational aspects of EMS that separates it from medicine. Probably one of the best examples is the fact that an EMS call starts before patient contact. A physician SOAP note’s HPI generally starts out with something along the lines of “a __ y/o M/F with a complaint of ___.” In a hospital, something might be added about how the patient arrived or why they are writing the note (such as a cardiology consult). In EMS, though, our call starts when we are dispatched, not when we arrive. In general, this section is one of the shortest sections. Where are you dispatched to, why were you dispatched, and how are you responding? Yes, I realize that the complaint coming from dispatch often doesn’t match the actual complaint that the patient has, which is of course the entire point of documenting it. Finally, did anything happen during the response? For example, there’s a few major rail lines running through my area and it isn’t unheard of to see emergency units waiting for the train to cross, or in one case leave the station since the arms are down when the train is in station due to the proximity of the station to the street, before they can proceed. It can turn an acceptable 5 or 6 minute response into an unacceptable 10+ minutes.
Pre-arrival: Unit 75 was dispatched code 3 to 1234 Arrow Drive for a patient complaining of chest pain. While en route, we were delayed approximately 4 minutes at an at-grade railroad crossing.