EMS Quiz:  Documentation and SOAP

Name: Student ID: Date:

When using the SOAP format your subjective section is what you are told. IE previous medical history, current medication and allergies and chief complaint. The objective section is what you see, hear, or feel.  Initial impression of patient, physical exam findings, and description of scene.  Assessment section lists what you treated for.  What was wrong for example possible broken leg.  What protocol was used.  This tells the reader of your report what you are treating.  Plan is what you did.  This should be in chronological order of the event of the call.  Tell the story of what you did and what changes took place.  It is your narrative of the call.

1. Patient was pale.

2. Medic 503 cleared the ED and returned to service. (Assume you are M503)

3. The patient's CC was "My chest feels tight."

4. Patient stated that his chest began to hurt 3 days ago.

5. Possible fractured leg.

6. No fluid noted from the nose, mouth or ears.

7. Patient was alert and orientated X 4.

8. Arrived on location, made contact with Engine 501.

9. Patient stated that he was diagnosed with coronary artery disease last year.

10. MI protocol followed for anginal episode.

11. Normal saline was delivered via macro drip set, 18g IV angio cath, right hand, with no signs of infiltration at a TKO rate.

12. The patient's pulse-ox was 85%.

13. "Dr. Phil told me in a dream that mowing the lawn was a good ideal."

14. Upon patient contact found a 55 year old male laying in the bath tub.

15. The patient was prescribed Nitro to take if he has chest pain.

16. Began ECG monitor and obtained a blood glucose reading.

17. Patient did not voice a complaint.

18. Vitals recorded at 19:20 hours.

19. Attempted first set of vitals and encountered problems with the blood pressure equipment.

20. Nursing home staff told us that the patient had fallen.

21. Distended abdomen with pulsating masses.

22. The staff advised that the X-rays did not indicate any problems.

23. A copy of all supplied nursing home paperwork was left with ED.

24. The patient's airway was patent upon evaluation.

25. The paperwork indicates that the patient has a past medical history of hypertension and Alzheimer's.

26. Patient transported on stretcher.

Retype the following sentences (located below the large answer box) into a SOAP report:

You can highlight the sentence's and paste it into the answer box if you choose to.

Hint: Label each sentence with a S, O, A, or P then start to write your report.

S in this box

O in this box

A in this box

P in this box

Place the following in the appropriate box.  Then read the report and see how it sounds.

Upon patient contact found 80 year old female sitting in chair awake and orientated X4. 

Arrived on location entered through main entrance. 

The patients airway was patent with no visible sings of respiratory distress. 

Obtained history from Engine 103 medic as well as nursing home staff. 

The nursing home staff told us that the patient has had abdominal cramping for the last 5 hours. 

M503 cleared the ED and returned back to service. (Assume you are M503)

The nursing home staff called 911 because further evaluation was needed by the ED.

Capillary refill was less than two seconds. 

There was no noticeable change in patient condition throughout care. 

The patient showed to be in a normal sinus rhythm on the ECG machine. 

Transported on stretcher with side rails up and seat belts secured.

A copy of report was left with the patient ED chart. 

Engine 103 was attending to patient upon arrival. 

D-stick taken in right index finger.

Patient's blood sugar was 130. 

A second set of vitals was recorded 10 minutes after the first set. 

M503's primary treatment concern was possible acute abdominal bleed. 

Began oxygen therapy, IV, ECG monitoring. 

Patient complained of nausea and one episode of vomiting. 

Checked blood sugar, and performed physical assessment. 

Possible diverticula's and obstructed bowel protocols considered.

Assessed ABC's and level of consciousness.