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06-07B Documentation Addendum, Page 1 of 4 Policy Addendum Patient Care Records Effective Date: July 1, 2014 Procedure Number 06-07B Addendum Revised Date: Number of Pages 04 1. “SOAP” and “CHART” documentation aids A. The "SOAP" format is a widely used in medical reports. It is easy to learn and helps organize the thoughts of the prehospital care provider as well as organize the report. It also allows organization of the data in a manner consistent with hospital records, thus makes interpretation by physicians and nurses easier. “CHART” is also an acceptable form of documentation. Both the SOAP and CHART report formats are provided here for your reference. An open narrative format is discouraged. B. SOAP "S" SUBJECTIVE FINDINGS • What the patient complains of or "History." • Chief complaint (preferably quoted in the patient's own words). • History of the present illness. (When did it start? What has happened since then?) • What makes it better or worse? What are the associated symptoms?) • Past medical history if pertinent. (History of diabetes? hypertension? Heart disease?) • Medications. (What meds are they normally taking? Any new ones? Any recreational / street drugs? Any they should be on, but ran out of?) • Allergies (particularly drug allergies). • Pertinent information from family, bystanders, witnesses. "O" OBJECTIVE FINDINGS – What “signs” you see, hear, feel, measure, or smell, on your physical exam. • General description. (Awake, unconscious, comfortable, in acute respiratory distress, combative, cooperative, etc.) • Full Vital signs trending over time. (Blood pressure, pulse, respiratory rate, capnography.) • Head-to-toe DCAP-BTLS − Head and neck, eyes, ears, nose, throat if pertinent. (Pupils equal or unequal, severe laceration, jugular venous distension, etc.) − Chest. (Crepitance, breath sounds, etc.) • Abdomen if pertinent. (Soft, tender, etc.) • Extremities if pertinent. (Tender, misshaped, edema, pulses, etc.) • Neurologic exam if pertinent. (AVPU - Unconscious, response to voice, response to pain, oriented, etc.) “A" ASSESSMENT – What do you think is the problem? • This is not a diagnosis, but rather an assessment of what the problem is for the patient. • “Cardiac arrest" does not need a "possible" with it. It is certainly appropriate, however, to list "possible" MI or fracture. “P" PLAN – What will you or did you do to help the patient? • Oxygen, immobilization, splinting, defibrillation, administration of medications, etc. • Record the response to each treatment and where the patient was transported. • ETA 06-07B Documentation Addendum, Page 1 of 4 C. CHART • “C” Chief Complaint • What the patient is complaining of. Also include age, gender, and weight. “H” History • Subjective information received from the patient. (SAMPLE) • History of the present illness. (When did it start? What has happened since then? • What makes it better or worse? What are the associated symptoms? • Past medical history if pertinent. • Medications. (Prescription, over the counter, diet supplements, home remedies, etc; compliance with medications) • Allergies • Pertinent information from family, bystanders, witnesses. “A” Assessment – Objective information obtained during your physical examination. • General description • Vital signs • Head-to-toe DCAP-BTLS − Head, neck, eyes, ears, nose throat if pertinent. − Chest − Abdomen if pertinent. − Extremities if pertinent. − Neurologic exam if pertinent. − Field Assessment of what you think is going on with the patient. “R” Rx/Treatment • What will you or did you do to help the patient. • Also document any response to the treatment you provided. “T” Transport • Facility transported to, mode of transport (emergent/non–emergent), why transported to that facility (request, closest, protocol, etc). 2. Narrative template A. A template may be used to aid in creating the ePCR narrative. An example is included for your reference. “Responded to reports of ____. On our arrival, found pt ____. Assessment performed, gathered history, performed vitals. Pt's medical history includes ____, allergies include ____, and prescription meds include ____. Pt's chief complaint ____, MOI, OPQRST, head to toe, DCAP-BTLS, etc GCS ____, Airway patent and maintained by pt, no breathing problems, no circulation problems. VS within normal limits. Other pertinent findings include ____. Loaded pt on stretcher, secured via 3 seat belts and loaded on Gold Cross Ambulance. Initiated transport 10-40 to ____. PCR called in to ____. IV access secured. No other pertinent or relevant changes en route. Final face to face report provided and care transferred to ED staff.” 3. Approved medical abbreviations A. The following medical abbreviations are used throughout healthcare and have been approved for use in SLCFD ePCRs. 06-07B Documentation Addendum, Page 2 of 4 airway, blood glucose cerebrovascular ABC breathing, BGL CVA G Gram level accident (stroke) circulation Advanced Glasgow Coma ACLS Cardiac Life BVM bag–valve–mask D50 Dextrose 50g GCS Scale or Score Support acute coronary ACS C Celsius D5W dextrose 5% in water GSW gunshot wound syndrome Deformity, Contusions, Automatic Abrasion, DCAP- AED External CC chief complaint Puncture/Penetration, gtts drops BTLS Defibrillator Burns, Tenderness, Laceration, Swelling Advances Emergency congestive heart Hazardous AEMT CHF DNR Do Not Resuscitate HAZMAT Medical failure materials Technician altered level of central nervous ALOC CNS ECG electrocardiogram HTN hypertension consciousness system Advanced Life Emergency ALS CO carbon monoxide ED Hx history Support Department against Emergency Medical AMA CO2 carbon dioxide EMS ICS intercostal space medical advice Services chronic acute obstructive Emergency Medical impedance AMI myocardial COPD EMT ITD pulmonary Technician (BLS) threshold device infarction disease Appearance, Pulse, cardiopulmonary ET APGAR Grimace, CPR endotracheal tube IM intramuscular resuscitation tube Activity, and Respiration Cincinnati Alert, Verbal, Prehospital estimated time of AVPU Pain, CPSS ETA IO intraosseous Stroke Scale arrival Unresponsive (stroke) continuous Basic Life intravenous BLS CQI quality F Fahrenheit IV Support catheterization improvement Facial and Arm cerebrospinal weakness, Speech BP blood pressure CSF FAST IVP intravenous push fluid difficulty, Time (stroke) Flow Restricted FROP- BS breath sounds C–spine cervical spine Oxygen Powered – J Joule VD Ventilation Device Body Color, Jugular Vein BSI Substance CTC Temperature, g gauge (diameter) JVD Distention Isolation Condition 06-07B Documentation Addendum, Page 3 of 4 L liter MS morphine sulfate P pulse RR respiratory rate left lower premature atrial right upper LLQ NC nasal cannula PAC RUQ quadrant contraction quadrant last menstrual Pediatric Advanced LMP NCR no care required PALS Rx medications period Life Support Signs/Symptoms, Allergies, Medications, loss of LOC NG tube nasogastric tube PCC Poison Control Center SAMPLE Pertinent History, consciousness Last oral intake, Events leading to the emergency left upper LUQ NOI Nature of Illness PCR Patent Care Report SL sublingual quadrant nasopharyngeal shortness of MAL midaxillary line NPA PE pulmonary embolus SOB airway breath medical anti– Non-Rebreather pulseless electrical MAST NRB PEA SQ subcutaneous shock trouser oxygen mask activity synchronous normal saline (IV Pupils Equal Round mcg microgram NS PERRL synch (switch on fluid) and Reactive to Light defibrillator) Mass Casualty normal sinus Prehospital Trauma transient MCI NSR PHTLS TIA Incident rhythm Life Support ischemic attack to keep open midclavicular MCL NTG nitroglycerin PM Paramedic TKO (minimum IV line rate) medications meds O2 oxygen PMS Pulse, Motor, Sensory Tx Trauma (Rx) paroxysmal ventilation mEq milliequivalent OB obstetrical PSVT supraventricular vent assistance tachycardia machine v-fib / ventricular mg milligram OD overdose Pt Patient VF fibrillation myocardial online medical premature ventricular MI OLMC PVC VS vital signs infarction control contraction oropharyngeal v-tach / ventricular mL milliliter OPA QA Quality Assurance airway VT tachycardia Onset, Provocation, Mechanism of within normal MOI OPQRST Quality, RLQ right lower quadrant WNL Injury limits Radiation, Severity, Time 06-07B Documentation Addendum, Page 4 of 4 .
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