Help with SOAP format and Narrative.

[SC Bird]

I am writing patient reports from my first internship. I've got the SO pretty good...and the P...but as far as the A goes, I am stuck.

What exactly are you supposed to document/note in the Assessment portion of your paperwork. I've read various things about noting obvious injuries, ruling out possible illnesses, etc....but for an abdominal pain such as my first call (see this thread for specifics http://www.emtlife.com/showthread.php?t=5595 ) , I don't really know what to document.

Anyone got some advice??

Thanks...

-Matt

 

[akflightmedic]

The "A" portion of SOAP format is easy. This is where you put what you think it was...your "working diagnosis".

The abdominal patient becomes...ABD pain.
Since you dont kow why, you could add "unknown etiology".

This section is very simple and at your level should be one to two words...thats it.

Good Luck!

 

[SC Bird]

Dumb question: what's etiology??

I appreciate the help flight...

-Matt

 

[Asclepius]

Dumb question: what's etiology??

the cause or origin of disease.

 

[Ridryder911]

Etiology- the meaning or purpose, cause..

Think of your PCR as a jig saw puzzle, that each part is telling a story For example your abdominal pain should have a history of onset, length, associated s/s i.e. nausea, vomiting, diarrhea, last bowel movement, etc.

Assessment should be focused upon your examination such as the visual appearance of the abdomen being flat, round, distended, obesed, etc? Then what was found on more detailed assessment upon palpation, soft, palpable, rebound tenderness, masses, pulsations, rebound tenderness? ..."i.e abdomen round, obese, soft palpable, with guarding in right lower quadrant, no masses or pulsations noted.."

Practice makes perfect... If possible read over your preceptors and others to see multiple examples. See what format "paints" a better descriptive picture.

Good luck,
R/r 911