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S.O.A.P. NOTES - Writing It All Down
by Nate Kennedy
When possible, everything that has happened at the scene should be written down. The SOAP Note is a widely accepted way to record the situation.
S.O.A.P.: Subjective, Objective, Assessment, Plan
SUBJECTIVE:
What Happened? MOI/HPI? Two Whom (name, age, sex)? OPQRST? If possible, use the patient’s words.OBJECTIVE:
How as the patient found, in what position? What was revealed by the physical exam? What were the vital signs? How did they change over time? What is the pertinent medical history? SAMPLE? Are there important negatives, such as “The patient was examined and revealed no pain or tenderness.”ASSESSMENT:
What are potential problems?PLAN:
What are you going to do? What things will you be looking out for, or have to be dealing with? (For example, open wound that has been cleaned and dressed, you will be looking out for infection, and transportation may be an issue, as well as shock). Is something written for every assessment you’ve pointed out? What changes will you be anticipating as time goes on?
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