EMS Documentation Part 4: The Objective and Assessment
EMS Documentation Part 3: The Subjective
EMS Documentation Part 2: Pre-Arrival
EMS Documentation Part 1: Introduction
After much delay, I’m finally getting around to finishing up this series. The next step, and final step in a -traditional- SOAP note, is the plan section, and the only one in chronological order (however in this modified version, pre-arrival, plan, and delta are all in chronological order). The plan is, simply put, your treatment plan. So, for our chest pain patient our plan might look something like the following,
- Supplemental oxygen titrated for respiratory status and SpO2.
- Continuous cardiac monitoring and 12-lead EKG
- IV access
- Position of comfort
- Emergency transport to nearest emergency department [or whatever your local system term for the emergency department is].
Ideally, list all of the treatments that you are considering based on your assessment. An isolated extremity fracture may warrant pharmacological pain management, so include it as a PRN treatment and simply note in the next section if it wasn’t given. A patient with a suspected opioid overdose would include something along the lines of “Naloxone, 0.5 mg IVP PRN for respiratory depression.” This section serves as a quick summery of what interventions you’re considering as well as providing an easily readable report in an organized format. By including interventions that are being considered, but might not be necessary, you’ve provided yourself an opening to document why, which is helpful if you need to review the call sometime in the future. Additionally, if anything worth noting as not being indicated, that otherwise would be, can be written here. For example, a trauma patient who falls under a selective c-spine protocol like NEXUS or Canadian C-Spine Rule would be worthy of a quick note (“C-spine immobilization not indicated under Canadian C-Spine Rule”).
The final section of Pre-SOAPeD is the “delta” or changes section. As mentioned earlier, a prehospital care report serves the purpose of both a history and physical, as well as a progress note. Here is where the nitty gritty treatment details goes (like assessing pulse/motor/sensation on a patient before and after placing a splint, or details on times, quantities, and route of medications administered), and would also go in chronological order. Additionally any changes in a patient’s status would fall under here. Our chest pain patient could see something like the following:
“Following assessment, the patient was placed on supplemental oxygen via NRB at 15 liters/min. A 12 lead EKG was obtained as described in the objective (copy included). [Say, sinus tachycardia with a prominent S wave in lead I and a Q wave with inverted T wave in lead III, since I didn’t include this earlier]. IV access was obtained with an 18 gauge angiocatheter with saline lock was started in a left AC vein. The patient was secured to the gurney via seat belts placed in semi-fowlers. Patient was transported emergently to House of God Medical Center. The patient was reassessed in route with no change in status. Upon arrival, the patient was transferred to a hospital gurney via draw sheet and care transferred to Nurse Molly and Dr. Roy Basch.”