SOAPs are referring to SOAP reports or SOAP notes.
It is a record of all the information you have gathered on a patient.
They are used in several ways, my wife uses one form for her PT work, for wilderness medical situations it includes the current condition of the patient, the history of what led up to their current condition, your diagnosis and treatment plan including your plan to evacuate or manage along with any anticipated problems and requests for equipment and assistance.
(From the Book) - just for fun and a good review!
S = Subjective/Summary/Story
"I have a (age, sex) whose chief complaint is (description of symptom including Onset, Provokes/Palliates, Quality, Radiation/Region/Referred, Severity and Time). Patient stated Method of Injury or History of Present Illness.
O = Objective/Observations/Findings
"Patient found (describe position). Patient exam reveals (describe injuries). Vital signs at (time), SAMPLE"
Vital Signs include:Time, Level Of Responsiveness, Hearth Rate, Resperitory Rate, Skin Color Temperature Moisture, Blood Pressure, Pupils, Temperature.
SAMPLE includes: Symptoms, Allergies, Medications, Pertinent medical history, Last intake/output, Events leading to the incident/illness.
A = Assessment (problem list)
P = Plan (Plan for each problem on the assessment list)
There are essentially three varieties:
Written - the most detailed.
Verbal Complete - a verbal version of the written, to be used to debrief or update people new to the scene or to be used with solid and reliable methods of communication such as a telephone land line.
Verbal Headlines - a down and dirty overview to be used when time is an issue when updating new people or when using unpredictable forms of verbal communication such as mobile phones or radios.
Brian
It is a record of all the information you have gathered on a patient.
They are used in several ways, my wife uses one form for her PT work, for wilderness medical situations it includes the current condition of the patient, the history of what led up to their current condition, your diagnosis and treatment plan including your plan to evacuate or manage along with any anticipated problems and requests for equipment and assistance.
(From the Book) - just for fun and a good review!
S = Subjective/Summary/Story
"I have a (age, sex) whose chief complaint is (description of symptom including Onset, Provokes/Palliates, Quality, Radiation/Region/Referred, Severity and Time). Patient stated Method of Injury or History of Present Illness.
O = Objective/Observations/Findings
"Patient found (describe position). Patient exam reveals (describe injuries). Vital signs at (time), SAMPLE"
Vital Signs include:Time, Level Of Responsiveness, Hearth Rate, Resperitory Rate, Skin Color Temperature Moisture, Blood Pressure, Pupils, Temperature.
SAMPLE includes: Symptoms, Allergies, Medications, Pertinent medical history, Last intake/output, Events leading to the incident/illness.
A = Assessment (problem list)
P = Plan (Plan for each problem on the assessment list)
There are essentially three varieties:
Written - the most detailed.
Verbal Complete - a verbal version of the written, to be used to debrief or update people new to the scene or to be used with solid and reliable methods of communication such as a telephone land line.
Verbal Headlines - a down and dirty overview to be used when time is an issue when updating new people or when using unpredictable forms of verbal communication such as mobile phones or radios.
Brian
