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Pre-SOAPeD Documentation

Importance of Documentation

  • Documentation is an important and often neglected part of patient care. Strong documentation protects both the patient and the EMS provider.
  • Documentation should be thorough and paint a complete picture of the patient, their emergency and the care provided.
  • The more information you can give to the physicians at the hospital the more time you save for your patient and the better care they receive.
  • Poor documentation has been associated with increased mortality in certain patients.
  • Goal: To write thorough enough documentation to prevent the need for in-person deposition for litigation.

Documentation Formats

  • There is different formats for documentation including CHART, Timeline Narrative, SBAR, and SOAP.
  • The Pre-SOAPeD format created by Joe Paczkowski on his blog EMT-Medical Student has become my preferred method for documentation.
  • It is thorough, straightforward and helps bridge the gap between pre-hospital care reports and the in-hospital charts and progress notes.

Pre-SOAPeD Reporting Checklist

  • Pre-arrival
    • Ambulance Unit Number
    • Emergent/Non-Emergent Response
    • Call Type
    • Location
    • Crew type
    • Delays
  • Subjective
    • Chief Complaint
      • Age/Sex of patient
      • Position of the patient when found.
    • History of Present Illness
      • Signs and Symptom
      • Onset, Provocation/Palliation, Quality, Radiation, Severity, Time, Interventions
    • Allergies/Medications
    • Medical/Surgical History
    • Family/Social History
    • Review of systems (As Applicable)
      • General
      • Neurological
      • Psychological
      • Head, Ears, Eyes, Nose, Throat (HEENT)
      • Cardiovascular
      • Respiratory
      • Abdomen
      • Gastrointestinal/Genitourinary
      • Musculoskeletal
      • Hair, Skin, Nails
  • Objective
    • Initial Assessment
      • Initial Vital Signs
      • Mental Status
      • Airway, Breathing, Circulation
    • Secondary Assessment (Body System As Applicable)
      • General
      • Neurological
      • HEENT
      • Cardiovascular
      • Respiratory
      • Gastrointestinal/Genitourinary
      • Musculoskeletal
      • Hair, Skin, Nails
      • Lab Values (SpO2, EKG, BGL, etc)
  • Assessment
    • Primary Impression
    • Additional items of your differential that you cannot rule out.
  • Plan
    • Treatments, interventions, dosages, equipment sizes
  • Delta (“change,” or response to treatment) and Hand-Off
    • Patient’s response to treatments
    • Vital Changes
    • Reassessments
    • Transfer of care
      • Nurses name
      • Bed patient moved to
      • Status of patient at transfer

See: Pre-SOAPeD Examples

Review of Systems

  • An inventory of the body systems obtained by identifying the absence or presence of various signs and symptoms.
  • With a problem-focused assessment, the review of systems should be related to the chief complaint and EMS Provider’s primary impression.

Review Of Systems Checklist

General: Fever, Chills, Malaise, Fatigue, Night Sweats, Weight Changes
Neuro: Seizures, Syncope, Loss of Sensation, Weakness, Paralysis, Loss of Coordination, Memory Issues, Muscle Twitches, Signs of Stroke
Psychological: Depression, Mood Changes, Difficulty Concentrating, Anxiety, Irritability, Sleep Disturbances, Fatigue During the Day, Suicidal and Homicidal Thoughts
HEENT: Headache, Dizziness, Loss of Consciousness, Blurred Vision, Light Sensitivity, Double Vision, Halo or Auras, Changes to Sense of Smell, Epistaxis, Postnasal Drip, Sinus Pain, Sore Throat, Bleeding, Dental Issues, Ulcers, Changes to Sense of Taste
Cardiovascular: Chest Pain, Edema, Palpitations, Tachycardia, Arrhythmias, Hypertension, Cardiac Medications,
Respiratory: Shortness of Breath, Wheezing, Dyspnea, Orthopnea, Cough, Sputum Production, Hemoptysis, Bronchitis, Tuberculosis, Pneumonia, Asthma, Respiratory Infections
GI/GU: Appetite, Heartburn, Nausea, Vomiting, Diarrhea, Constipation, Hematemesis, Changes in Stool. Flatulance, Jaundice, Dysuria, Increase Frequency or Urgency of Urination, Hematuria, Flank or Suprapubic Pain, Erectile Dysfunction, Fluid Discharge, Testicular Pain, Menstrual Regularity, Last Menstrual Period, Dysmemorrhea, Vaginal Discharge, Abnormal Bleeding, Pregnancies, Contraception Use.
Hair, Skin, Nails:
Rash, Itching, Hives, Sweating, Bruising, Bleeding. Changes to Hair Color, Texture, Abnormal Loss or Growth. Changes to Nail Color, Brittleness, Texture.

Cite this article as: Scott Kostolni, EMT-P, "Pre-SOAPeD Documentation," from SickPatient.com, November 2, 2017, date accessed: November 28, 2022 https://sickpatient.com/documentation/

Resources and References

  1. Featured Imaged by NEC Corporation of American under Creative Commons License.
  2. Dana J. Laudermilch, Melissa A. Schaffer, Avery B. Nathens, Matthew R. Rosegart, Lack of Emergency Medical Services Documentation Is Associated with Poor Patient Outcomes: A Validation of Audit Filters for Prehospital Trauma Care, In Journal of the American College of Surgeons, Volume 210, Issue 2, 2010, Pages 220-227, ISSN 1072-7515, https://doi.org/10.1016/j.jamcollsurg.2009.10.008. (http://www.sciencedirect.com/science/article/pic/s1072751509014902)
  3. Mulvehill, S., Schneider, G., Cullen, C. M., Roaten, S., Foster, B., & Porter, A. (2005). Template-guided versus undirected written medical documentation: a prospective, randomized trial in a family medicine residency clinic. The Journal of the American Board of Family Practice 18, no. 6 (2005): 464-469
  4. Paczkowski, J. (2011, January 20). EMS Documentation: Introducing Pre-SOAPeD. Retrieved November 2, 2017, from https://emtmedicalstudent.wordpress.com/2011/01/20/ems-documentation-introducing-pre-soaped/
  5. LeBlond, R.F., DeGowin, R. L., & Brown, D. D. (2009) Degowin’s diagnostic examination (9th ed.). New York: McGraw-Hill Medical.
  6. www.cms.gov. (December 2010). Evaluation and Management Services Guide. Updated August 2017. Accessed November 2, 2017, from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

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