EMS Documentation Part 3: The Subjective
First off, apologies. Medical school started really kicking my butt and this had to take a back seat to actually passing courses. Now that I’ve got a little more free time as school winds down and board studying winds up, hopefully I’ll be able to keep a little more resemblance of an actual update schedule. Similarly, once rotations starts hopefully I’ll be able to post something a little more interesting (and hopefully just as helpful) than the majority of these posts.
The next step in the Pre-SOAPeD format is the objective section. There really is not much too actually say about the objective, to be honest. The section starts with vital signs and then follows with the same head to toe format as the review of systems (ROS). The only difference is that while the ROS covered questions, the objective section covers your physical exam. So skin signs go under “skin.” Pupils can go under HEENT or neurological. Breath sounds goes under respiratory. So on and so forth. At the end of the Objective is where the lab values are recorded. The normal point of care testing for EMS is the EKG and cardiac monitoring, pulse oxymetry, capnography, and blood glucose testing. Similarly, the format of the Objective section is also the same as the ROS. Each location (vital signs, HEENT, neck, resp, C/V, etc) are their own paragraph.
Following the Objective is the Assessment section. The Assessment section is probably one of the most misunderstood sections of SOAP notes in EMS. First off, we generally use “assessment” as synonymous with patient assessment. Second, it forces us to break one of the ‘cardinal rules’ of EMS, namely not making a diagnosis. The “assessment” in terms of a SOAP note is -your- assessment of what’s going on. It’s your working diagnosis (what you’re treating), as well as your differential diagnosis (what else could be going on). So, going off of the subjective section of our patient posted earlier, what’s going on? Shortness of breath, chest pain, hemoptysis? Well, pulmonary embolism, pneumonia (coughing so much to damage the mucosal lining of the airway?), secondary TB, acute coronary system (chest pain after all) and probably a few others we could think of. With a good physical exam and POC testing, you could probably rule a few of these out, thus strengthening your case for what you’re treating. I’ll discuss the benefits of actually listing what you think you’re treating at the end of the series.