Transcript SOAP notes

SOAP notes
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Subjective: (age, sex, mechanism of injury (MOI), chief complaint (c/c) & description of pain P.Q.R.S.T.)
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Objective:
vital signs (VS), patient exam (PE), AMPLE history
Time
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Level O Cons. ____
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Vital
Respir. Rate ____
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Heart Rate
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Blood Press.
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Skin (C.S.M.)
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Pupils
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Temp
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Signs
Patient exam: Describe location of pain and injuries
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AMPLE:
Allergies
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Medications _________________________________________
Previous injury or illness__________________________________
Last Meal
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Events leading up to the accident___________________________
Assessment:
(problem list)
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2.________________________________________________________________
3.________________________________________________________________
4.________________________________________________________________
Plan:
(plan for each problem on the problem list - bivouac, transportation, etc.)
1.________________________________________________________________
2.________________________________________________________________
3.________________________________________________________________
4.________________________________________________________________
5.MONITOR - How often do you plan to monitor the patient_________________
Provokes
Quality
Radiates
Severity
Time
Alert
Verbal
Pain
Unresponsive
Color
Sensation
Moisture