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  • SOAPNote Template

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    Janet Diffey
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    This document contains templates for documenting a patient assessment using the SOAP note format. The SOAP note sections include: 1) Subjective: Information reported by the patient such as chief complaint, history of present illness, allergies, medications 2) Objective: Findings from physical exam such as vital signs, appearance, affected body areas 3) Assessment: Analysis of the patient's condition including suspected injuries or illnesses 4) Plan: Treatment plan and instructions for patient care

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    SOAPNote.template

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    This document contains templates for documenting a patient assessment using the SOAP note format. The SOAP note sections include: 1) Subjective: Information reported by the patient such as chief complaint, history of present illness, allergies, medications 2) Objective: Findings from physical exam such as vital signs, appearance, affected body areas 3) Assessment: Analysis of the patient's condition including suspected injuries or illnesses 4) Plan: Treatment plan and instructions for patient care

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    473 views2 pages

    SOAPNote Template

    Uploaded by

    Janet Diffey
    This document contains templates for documenting a patient assessment using the SOAP note format. The SOAP note sections include: 1) Subjective: Information reported by the patient such as chief complaint, history of present illness, allergies, medications 2) Objective: Findings from physical exam such as vital signs, appearance, affected body areas 3) Assessment: Analysis of the patient's condition including suspected injuries or illnesses 4) Plan: Treatment plan and instructions for patient care

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    Patient Assessment SOAP Note

    Cut Here
    Patient Name: Date: Time: Date: Time:
    Airway Name: Age:

    Patient
    Breathing Address: M or F
    Circulation Phone: Notify:
    Disability Relation: Phone:
    (moi c/c opqrst)
    Environment

    Subjective
    Focused Exam
    Head/Neck
    Shoulders/Clavicle
    Chest/Sternum
    (Patient Exam SAMPLE History)
    Abdomen
    Pelvis/Hips

    Objective
    Legs/Feet
    Arms/Hands
    Back Cervical Thoracic Lumbar Sacrum Coccyx

    Get Vitals Time AVPU HR/Character RR/Character SCTM

    Vital Signs
    Time
    Level of Responsiveness (AVPU)
    Heart Rate/Rhythm/Quality
    Respiration Rate/Rhythm/Quality
    Skin Color/Temp/Moisture
    History

    Assessment
    Chief Complaint
    MOI (Mechanism of Injury)
    Symptoms
    Onset
    Provoke/Palliate
    Quality
    Radiate (Leads to where?)
    Severity (1-10)
    Trend (When did it start)
    Plan

    Allergies
    Medications
    Cut Here

    Pertinent History
    Last Intake/Output
    Events Preceding
    Rescue Request Vital Sign Record

    Cut Here
    Quadrangle/Coordinates Time Heart Rate Respiratory Rate Skin LOR BP
    Location

    Area Description
    Character: Character:

    Breaths Per
    Strong Deep

    Beats Per
    Weak Shallow Color

    Minute

    Minute
    Date Regular Noisy Temperature Blood
    On The Scene

    Stay Put Evacuate to trail to road to local shelter Hour Irregular Labored Moisture AVPU Pressure
    Will send some members out
    Plans

    Notes:

    Food Water Shelter Stove and Fuel


    Equipment
    Needed

    Sleeping Bags Climbing Hardware Rope


    Notes:

    Temp: Hot Warm Cold Freezing


    Weather

    Precip: Dry Intermittent Rain Rain Snow


    Notes:

    Lowering Operating Carry Out Rigid Stretcher


    Evacuation
    Type of

    Helicopter None until specialized medical assistance


    Notes:

    Name Notify Phone


    Remaining Party Members
    Notes

    Cut Here

    Focused Spine Exam: Date__________ Time___________ Patient Assessment/History Complete______

    Reliable (A+0x3, Sober, No Distract Injury)______ CSM (4 Extremities)______ No Spine Tenderness______

    DBB 11/01/07

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