Previously:
EMS Documentation Part 1: Introducing Pre-SOAPeD
EMS Documentation Part 2: Pre-arrival
First off, a little disclaimer. Since I lack an imagination, the story used to illustrate the SOAP narrative is from a standardized patient (actor) encounter and not a real patient. No hippos were offered to the HIPAA God to appease for any offenses.
Starting with the Subjective section of the SOAP note is where we return to what a normal SOAP note contains. SOAP notes, in large part, do a good job of following the natural course of an assessment, which is one of the many benefits. After all, what’s the first thing that you want to learn about a patient’s problem? “What happened? What changed?” of course, which is the entire purpose of the “History of Present Illness” (HPI). The HPI is the background of our story. It starts off with the main character (“50 y/o F…”), the title of our little story (“…presenting with a chief complaint of chest pain.”) and continues with the rest of the background. This is where the ever popular OPQRST goes, as well as anything else pertinent to this question. Things like, “What else happened?” If the patient might have suffered a seizure, you might ask or look to see if the patient bit their tongue. Has the patient taken anything? Did it make it worse or better? Does the patient have a medical history that contributes to it?
Following the HPI is medical history, allergies, medications, and surgical history. It really doesn’t matter the order for these 4.
Medical history/Surgical History: Note when the condition occurred or started. Don’t forget to ask about childhood diseases. “Nope, I’m healthy” could easily be, “I had childhood asthma that resolved during puberty, so I have nothing wrong… now.”
Medications: Don’t forget to ask how much, how often, and for what. Additionally, medications includes prescription, over the counter, and supplements, and the last two are often not thought about.
Allergies: To what, and what reaction? An allergy, sensitivity, and an adverse reaction are all three different things, but most non-medical people will group those 3 together.
Family History: Who had what, when? A 40 year old who had parent die at 45 from a MI is a rather important thing to know.
Social History: Drugs, alcohol, and tobacco: What, how much, how often? What does the patient do? A coal miner with a hacking cough and a preschool teacher with a hacking cough can be two drastically different things. Additionally, if you take a sexual history (discussed here), it gets thrown in here.
The final section, and the other section, along with the HPI, where all of the money is, is the Review of Systems (ROS). The Review of Systems is basically the rest of your questions and serves two important parts. First, it finishes flushing out the patient’s complaint. Second, it also screens for other complaints and issues that may or may not have anything to do with the chief complaints. It’s your backstop that allows you to catch anything you missed in the HPI. In general, some of it should be asked from all patients, regardless if it’s immediately pertinent or not.
Also, the ROS is structured slightly differently from the rest as it’s divided up by location. The general order goes “General,” Head/Ears/Eyes/Nose/Throat (HEENT), Neck, Cardiovascular, Respiratory, Abdominal, GU/GI, Extremities, Skin, Neuro, and Psych. However, as with everything else, this is slightly customized. If you think the patient may have an endocrine complaint, throw in an endocrine section to organize the different pieces of question.
Subjective:
HPI: Patient is a 40 y/o female with a chief complaint of chest pain. The pain started about 2 hours ago while the patient was carrying laundry down stairs. The chest pain is a sharp pain, 8/10 in the right chest radiating to the back. The pain is worse during inhalation and better in exhalation. The patient took aspirin about an hour ago and tried to rest. Neither provided relief. This is the first time she’s had pain like this. She is also complaining about some shortness of breath with a slight cough producing mild hemoptysis, but denies sneezing, congestion, or sputum production.
Medical History: None.
Allergies: NKA
Medications: Yasmin: Oral contraceptives, 1 dose per day in AM.
Family history: None, both parents are still alive.
Social History: Patient smokes about half a cigarette a day. She denies alcohol and recreational drug use. She is a stay at home mom.
Review of systems:
General: No fever or chills. No weakness. No loss of consciousness. No weight gain or weight loss. No dizziness.
HEENT: Denies changes in vision or hearing. Denies head congestion. Denies difficulty eating. Denies nose bleeds.
Neck: denies pain and tenderness.
Cardiovascular: Complains of chest pain, 8/10. Denies palpitations, dyspnea on exertion, and Orthopnea.
Respiratory: Complains of difficulty breathing with slight hemoptysis. Increased pain on inhalation. Denies sneezing and feelings of congestion.
Abd: Denies nausea, vomiting, diarrhea. Denies abdominal pain.
(Add more as appropriate. Google or resources like Bates Guide to the Physical Exam can provide a more complete list of things to ask for a ROS).
Next: EMS Documentation Part 4: The Objective and Assessment
EMT-Medical Student 
If I may, JP, add a few example from my presentation on hx taking for first aiders:
Things that people don’t think are medical problems:
“I had a car accident and spent 3 weeks in hospital last month.” (Its an injury, its fixed now so its not relevant. An injury is not a medical problem).
“I see a psychiatrist weekly for Bipolar maintenance” (A psychiatric or psychological problem is not medical).
“I’ve been having these fainting spells” (Problems with health that haven’t been qualified by a doctor aren’t medical problems).
How you word your questions:
“Have you been in pretty good health lately” = “How’s it going?” (Many will answer yes, in the same sense we say “yeah not to bad” when people greet us with a similar question. Have you been sick, seen a doctor, or had any concerns with your health in anyway in the past six months. VERY DIFFERENT.
“Have you GOT any problems with your heart?”
“Have you EVER HAD any problems with your heart?” (People often think once a heart problem has been fixed, stented, CAG’d, its not relevant anymore, like a healed cut or a bruise. )
Oh sure, feel free to add. I’m mostly focusing on documenting rather than communication skills.
However, now that we’ve touched on it, here’s a few more good assessment tips.
Especially if you’re starting with a more generalized complaint, start broad and move specific. “Do you have any problems with your head?” is a good way to start off asking about the head. Follow it up with “Do you have any changes in vision/hearing/nasal drip/tenderness/etc?” Do you have any problems breathing? So no shortness of breath/coughing/sneezing/sputum production/pain when breathing, etc?
To reiterate for the TL/DR crowd, childhood illnesses may not come up. Medications is prescription, over the counter, and supplements.
Today, I went to the beachfront with my children. I
found a sea shell and gave it to my 4 year old daughter and said “You can hear the ocean if you put this to your ear.” She put
the shell to her ear and screamed. There was a hermit crab inside and it pinched her ear.
She never wants to go back! LoL I know this is completely off topic
but I had to tell someone!