SOAP NOTE INCIDENT FORM

NAME: John Citizen

DATE: 20 September 2016
SUMMARY- Emergency Services Contact Information
-

We require an ambulance. My name is Ty Burkett and we are a Flinders University group.

Our location is 501-511 (grid reference) and we are approximately 2km from the Deep Creek Cove Hike from Trig
Picnic Area, which is situated along tent rock road.
We have a casualty who is a 20-year-old male whose Chief Compliant is: That he has extreme pain in his right
ankle after falling while carrying a 20kg backpack and states he is unable to place weight on the right ankle. The
casualty also has grazes and bruising along his right arm and hand after using them to brace his fall.
The patient states/witness states: The patient has had no previous ankle or arm injuries. All participants
remained unaffected by the incident.

Onset of the event: hiking, stepped on unstable terrain

Provocation or palliation: weight on the injury causes added pain
Quality of the pain: Mild to serve throbbing pain
Region and radiation: left ankle, comes up the leg
Severity: 7/10
Time (history): same symptoms
OBSERVATIONS
Patient Exam
After falling over and having pain, the patient was found on the ground grasping his ankle. The patients exam reveals
bruising and swelling in and around his right ankle, as well as grazing and inflammation along his left arm and hand. He
was in a stable condition and has been quite calm throughout the incident.
Vital Signs
NORMAL
TIME
AOX4
LOC
50-100bpm
HR
12-20
RR
SCTM PINK/WARM/DRY
TEMP 37 deg

1
13:05
AOX4
125
20-25
Red/warm/clammy
38 degrees

2
13.15
AOX4
110
20-25
Red/warm/clammy
37.5degrees

3
13.25
AOX4
100
12-20
Red/warm/clammy
37degrees

4
13.35
AOX4
100
12-20
Pink/warm/dry
37degrees

5
13.45
AOX4
90
12-20
Pink/warm/dry
37degress

HISTORY
Symptoms: nil
Allergies: nil
Medications: Ventolin
Pertinent medical history: nil
Last intake/output: food was consumed 45 minutes before incident. Water was consumed 5 minutes prior to incident
Events: has limited bushwalking experience
ASSESSMENT (Problem list) The student is unable to walk without assistance. The road is a 2km walk away.
PLAN
The members within the group will work together to assist the injured student in walking to the nearest road. The group
will also carry the injured students belongings by distributing the weight evenly amongst the group members. Medical
assistance will be contacted before walking to the nearest road, with our location and the patients status being
transmitted to them. Once we are at the road, maintaining safety within the group will be the priority.
.

ANTICIPATED PROBLEMs
It is anticipated that other injuries to other group members may occur due to supporting the injured student and carrying
his belongings. Another issue may be the time taken to access medical assistance, so it is essential to monitor the
whole group by keeping them warm, fed and hydrated. Maintaining safety of the remainder of the group is the highest
priority.