Documenting Medical Care

Facebook Twitter Tumblr Pinterest Email Plusone Stumbleupon Digg


Documenting medical care is important. Sometimes it is helpful to assign this task to anyone who is really just getting in the way. POST SHTF doctors and medical professionals aren’t going to just evaporate. Really the time between injuries and illness and definative care will be extended greatly. For this reason you will have to document what has been done.

You want to make a care report in a SOAP format. Subjective Objective Assessment and Plan.

y/o (year old) (M or F) c/o (complains of) x
Then you document what the patient tells you.

Objective: Here is where you include Vital Signs: BP (Blood Pressure), HR (Heart Rate), Temp (Temperature), RR (Respitory Rate)

Also include SAMPLE History. Signs and Symptoms, Allergies (NKA-No Known Allergies,NKDA-No Known Drug Allergies), Medications, Last oral intake (drinking and eating) Events that led up to the injury or illness

OPQRSTI. Onset of pain Provocation (what makes it better or worse) Quality (what does the pain feel like) Radiation (where does the pain travel) Severity (1-10 10 being the worst) and Time (how long has the pain lasted) Interventions (what has been done to releive the pain)

Assessment includes any examinations you have done such as labratory testing, x-rays, or P/E (physical exam.) Yes this step will be severely limited. Here is also what you diagnose the problem to be. This will be a field diagnosis since you are not a doctor. You signify this by stating R/U (rule out)

Plan This includes any treatment you do.

Here is what a SOAP note should look like.

25 y/o M c/o (R) shoulder pain x 2 days. PT states it is a ripping pain. PT states pain started acutely when he was punching ISIS combatant in the face. Point Tenderness to (R) shoulder. P/E revealed: Pain upon external rotation and flexion of (R) shoulder. HR 92 BP 124/68 RR 12. Temp 98.3 NKA. No Meds, Last Oral Intake 1805 on 1/19/15. R/U Rotator Cuff Tear. Sling and Swath, Heat Pad, Shoulder PT Exercises, Tylenolol 325mg. F/U (follow up) with Medic in 2 weeks or if symptoms worsen.

If you use this format and document every illness and injury in your family you will get good at this. It is EXTREMELY helpful in emergencies and for hospital staff if you can document this prior to arrival. It makes everything go much smoother. If you are talking over the Radio or Internet with a doctor this is the information they will want to know post SHTF. In a disaster it can be critical to triaging patients.

You can download patient care reports that will have all this information. Write in the Rain makes excellent EMT note books.

This article has been read [1096] times.

2 votes

About David Black

Trained and Certified: National Registry EMT, Wilderness EMT, US Army 68W, Tactical Combat Causality Care (TCCC), Basic Life Support for Healthcare Workers, Advanced Cardiac Life Support, Pediatric Advanced Life Support, US Coast Guard Medical Person In-Charge, Pre-Hospital Trauma Life Support. International Trauma Life Support. HAM Radio Technician. Trained and Certified to Instruct: Combat Life Saver Instructor and Community Emergency Response Team Trainer. CPR, AED, First Aid.

Leave a Reply

Your email address will not be published.