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SOAP. Or, How to Write a Clean Run Report (pun intended). S- Subjective This is where you paint your picture. Chief Complaint/ Mechanism of Injury OPQRST (Retrosternal chest pain, onset at rest, rated 5/10, dull and radiates to left arm and jaw and nausea)

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  1. SOAP Or, How to Write a Clean Run Report (pun intended)

  2. S- SubjectiveThis is where you paint your picture. • Chief Complaint/ Mechanism of Injury • OPQRST (Retrosternal chest pain, onset at rest, rated 5/10, dull and radiates to left arm and jaw and nausea) • Past Medical History (HTN, COPD, Angina, etc.) • Patient states,”It hurts when I pee.” (Quotes are good.)

  3. Subjective (cont.) • Don’t forget to write if the patient is SNF • -and/or- Meets the definition for bed confinement • -and/or- Could go by other means but you explained the NEMB form (and they signed it). • This could also be charted at the end of the narrative (after “P”).

  4. O- ObjectiveYour Assessment and Findings • Primary and Secondary survey results. • Head to toe positive and negative findings. • AVPU, Airway, Head/neck, Chest, Abdomen, Back, Extremities, Neuro, GU, cardiac monitor, O2 Sat, BGL, etc. • DO NOT RELY ON THE PROGRAM’S ASSESSMENT FEATURE. It’ll bite ya!

  5. “Exam Normal” or “WNL” does not tell the court anything about what you saw or assessed.Heck, it doesn’t even tell a lawyer if you actually assessed anything.Do you expect a lawyer (or Medicare) to believe you when you tell them you looked at their client’s belly after writing “Exam normal”?

  6. A- Assessment • Your Field Diagnosis/Suspected problem(s) • such as: Hypoglycemia • -or- 1) Hypotension, 2)Bradycardia • -or- Chest Pain secondary to Bradycardia • -or even- M.I. with ST elevation in Inferior leads.

  7. P- PlanWhat you did, in order that you did them (if possible). • Moved patient to stretcher and placed patient in POC (semifowler’s), O2 NC @ 4LPM, Vitals, 324mg ASA PO, Cardiac Monitor, 18ga IV Left AC, NS at KVO with 100cc’s infused, 12 Lead, 0.4mg NTG SL x 2 with complete relief of pain, reassess, reassure, turn care over to RN with report given, PCS form signed by Dr. No.

  8. Plan (cont.) • Remember to document if a therapy helped or made no change in patient condition (such as results of Fentanyl, NTG, etc.).

  9. You are CQI What would you add or subtract? Note: If you recognize the narrative as yours, don’t be afraid. CQI is a learning process. It’s when the same or similar issue is addressed time and again when management will step in.

  10. Narrative #1 S - Called to the home of a 40 y.o. female with a CC of side pain. Pt states she passed out, without a fall or any trauma. Pt CAOX3 UOA and sitting in a chair. Pt states her husband came home to take her to the hospital. PMH Hypotn, Asthma, Gastric BP, Anxiety, Panic Attacks, R Foot Surgery, and currently being evaluated for Gall Bladder and Ulcer problems. Meds ansd allergies as stated. No other c/o pain or discomfort. Medical Control via Dr. David Bachman of CMMC for fentanyl and promethazine as given below. O - Vitals below. +PE with pain on plap of right side, rest of PE = WNL. EKG and 12 Lead are NSR throughout Transport. BG = 108. LS clear Bilaterally. Assess pt, Spinal Assessment, IV, Med Control, Meds Reassess, Transport, Document.

  11. Questions? • Where was the pain? Which side? Quality? Quantity? How long? Radiation? • If no fall or trauma, why the spinal assessment? • Why the meds? Did the meds work? • 12 Lead or cardiac monitor? She got meds and she passed out. • Blood Glucose Analysis? • Anything else???

  12. Runsheet #2 [S] Called to {town/street removed for privacy}for a female who fell. HPI- female pt fell while walking along her deck. Board gave way and pt fell through the floor. Female denied any LOC neck or back pain. Pt was splinted upon our arrival. O female pt seated on couch. a- clear, b- unlabored, c = raqdial pulses heent -wnl neck - wnk chest - wnl. abd -wnl, legs- left ancle pain splinted prior to arrival. arms - right wrist pain. unable to get bp due to pt size and noise. [A] sprain / fracture right wrist left ancle {p} assessment, vitals, stairchair outside, to cot, transport poc, no changes enroute, pt moved via slipp to bed at Er .

  13. Questions? • Spelling. Spell check is available, use it! • Spinal assessment done? By who? • Who splinted PTA? • Pain on scale? Does she bear weight? • Swelling, deformity, (-) CMS? • IV? Meds? If not, did they refuse them? • Unable to get up due to noise???

  14. Runsheet #3 Called to SRNCC for an elderly male patient that had fallen and is complaining of hip pain. Nursing staff state patient had fallen in the bathroom this morning and is now complaining of back,neck and hip pain. Nursing staff state 'this is normal level of consciousness and breathing for this patient. Staff state patient scheduled for a neb treatment @ 0700 this morning so he hasn't had any of his meds yet. Patient states over and over 'Oh God, and I hurt'. Patient unable to apply a numerical value to the pain. PMH: dementia, chronic airway obstruction, depressive disorder. Upon our arrival we found a 87 year old male patient complaining of neck, back and hip pain. No obvious deformity was noted on exam. No DCAP-BTLS noted on exam, abdomen soft nontender.Cervical collar was applied, patient moved to longboard,oxygen applied ,oxygen saturation originally @ 88% increased to 95%. Limited secondary assessment due to short transport time. Patient care turned over to FMH ED staff without incident or further change.

  15. Questions? • Not in SOAP format (not always a bad thing so long as the info is there). • Any mention of C-collar or HID? • Anything else? (pretty good sheet IMHO)

  16. Questions?Don’t hesitate to contact Cory (491-1015 or cmorse@fchn.org), Tom (897-3611), or Wade (235-2228) if you need any help.

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