SOAP or CHART. (or something else)

[lightsandsirens5]

OK

Do you use the SOAP or CHART format. Do you like the one you use? If not, why?

We use SOAP, but I think it can lead to a vague report sometimes. (Especially at 0300 in the morning.)^_^

 

[Epi-do]

I write my reports chronologically. I have tried to use SOAP, CHART, and any other way you can think of, but noticed I would tend to leave things out. By doing it chronologically, I can replay the run in my mind as I am writing my narrative and make sure I don't forget anything.

 

[reaper]

I write mine chronologically also. I prefer to tell a story of the call. Anyone can read the PCR and understand what happened.

I have never been a fan of SOAP or Chart.

 

[mikie]

I really don't even remember much about those two. I too write it chronologically. "We arrived on scene to find..." so on a so forth. I know my PCRs are perfect, but I've never had a talking to about errors made.

 

[Hastings]

Dispatched priority __ to __. ATF __ y/o __ pt sitting in chair. Pt appeared ______. Pt stated __________. Assessment found _________. _______((Treatment))_____. Pt transported _______. Care transfered to ________.

Experience has shown me that those who write in a similar narrative format as the one above avoid the most problems and criticisms. It's just more in depth. Simple as that. I know plenty of people (firefighters, mostly) that use alternative methods such as CHART, and it works for them, but if you want to ensure your reports are as solid as possible, write the story out. You can rarely have too much information.

 

[Jochempeiper]

I enjoy doing PPCR's because I am very technical. When I call in a report it goes kinda like this: "Remsi Medic 10 to NRVMC on Med Channel 10. They'll answer back, then I'll start off by saying: " We are embound to your location with a -yadda yadda- year old male, called to the scene for a patient with chest pains, upon arrival patient advised that he has been having chest pains throughout most of the night and has taken 3 nitros with no relief, his BP is 90/30, and therefor we cannot give anymore NITRO. His vitals are as followed: BP 90/30, pulse 78, respirations 14, pupils are equal and react normally to light, GCS is 15, showing 97% on Room air, do you advice any further.

Then when I fill in a PPCR I report what we wen't to the scene for, what I found, how they got in the ambulance(ambulatory, or stretcher), procedures we did in the Ambulance, vitals, and when we turned over care to the Hospital Staff.

 

[Katie]

version of SOAP we call SOAPE. it seems to work pretty well. we have criteria for what needs to be in each section so it's not that hard once you get a feeling for it and it tends to be pretty complete (provided you are not slacking ).

 

[ffemt8978]

SOAP as mandated by the state DoH.

 

[JPINFV]

I write my reports chronologically. I have tried to use SOAP, CHART, and any other way you can think of, but noticed I would tend to leave things out. By doing it chronologically, I can replay the run in my mind as I am writing my narrative and make sure I don't forget anything.

Exactly the same thing I do. I had to laugh because at my old work they tried to standardize charting with a "Modified SOAP." Of course the only thing that their version of SOAP and the real SOAP had in common was the name SOAP. Of course that (due to lack of enforcement, encouragement, or anything else besides an ill circulated memo) went over like a lead balloon.

 

[br16]

Our Medical Director has us write ours in SOAP.....Not a fan of them at first, seems that I have to repeat myself many times, or that im not sure of where to put certain information about the pt. Though not a fan at first now, it is hard for me to write a report w/ out it. It started taking me a long time to write them, now i can crank them out in pretty good time. just my 2 cents

 

[upstateemt]

I use a chronological narrative starting with arrival on the scene; presentation of patient; chief complaint; assessment; treatment; transport and transfer of care. I find it an easy way not to leave something out.

 

[snaketooth10k]

Narratives FTW!

I find that everyone can read a narrative and most people can write them except for dislexic members. SOAP and CHART can be confusing sometimes even though they have been standard in medecine for at least 100 years.

 

[Flight-LP]

SOAP - It is the standard for physician's and mid-levels. It is a professional format and it is complete. Why wouldn't you want to use it with the exception of personal dislike????

 

[upstateemt]

SOAP - It is the standard for physician's and mid-levels. It is a professional format and it is complete. Why wouldn't you want to use it with the exception of personal dislike????

Because it is a confusing way to "tell the story" of the call. As a nurse (in a hospital) I have seen "SOAP" notes fad in popularity over the years in favor of a narative H&P. A well written narative is now standard in my hospital and is professional and complete record of the patients problem, whether it is found on a PCR or hospital chart.

 

[BossyCow]

We are mandated by the DOH to use the SOAP format. I have likes and dislikes with it. I find a lot of information is difficult to place in a SOAP format. While assessing an ABD, and the pt says "ow that hurts" is that subjective or objective? You have to put the same info in the report 2 times. Pt states pain 7:10 to URQ of ABD upon Palpation. in subjective. Pt shows visible discomfort to palp of URQ of ABD in objective. Also, since subjective is at the top, you have to go back and forth between the two to cover everything.

Not my favorite system, but the one I have to use.

 

[Oregon]

We use SOAP, but we are tweaking it to our needs. Our standard form has changed a couple of times, and still has redundant bits.
I wish someone had a really useful example of a wilderness SOAP note that I could steal ideas from

 

[lightsandsirens5]

We are mandated by the DOH to use the SOAP format. I have likes and dislikes with it. I find a lot of information is difficult to place in a SOAP format. While assessing an ABD, and the pt says "ow that hurts" is that subjective or objective? You have to put the same info in the report 2 times. Pt states pain 7:10 to URQ of ABD upon Palpation. in subjective. Pt shows visible discomfort to palp of URQ of ABD in objective. Also, since subjective is at the top, you have to go back and forth between the two to cover everything.

Not my favorite system, but the one I have to use.

Well...being in WA state myself, I gotta use it too.

I was told that the subjective data is what you are paged out to, word for word what dispatch says, and Objective is what you see immediately upon your arrival. Scene info such as:type of scene, location of scene, location of pt in that scene, inital general impression of pt, location of vehicles involved (if MVA), pt position in relation to vehicle, agenceys already on scene, etc.

Our report kinda goes like:

S: Page out
O: Inital on-scene data

Inital assment
A
B
C
C-spine
Pupils
LOC
Bleeding
Skin
Ongoing assessment
HEENT
Chest
Lung sounds
Heart
Abd/pelvis
Back
Extremitys
History
Past med Hx
LOI
Events leading to illness or injury

A: Possible.......
P: Plan: All procedures

Narritive is broken up into several parts made of S, O, Events and P.


So I guess you could call it the SOIAOAHxAP format with narritive. :unsure:

 

[mycrofft]

Our county tried to mandate SOAP but MD's rebelled.

My trouble is worst regarding handwriting. I use a gobbledeygook-S/O-gobbldeygook-O-gobble-P format. And a stamp with my printed name on it for use after my signature.
I also sketch in the left margin. I can spend ten minutes (well, one minute) describing "a finely papular erythematous area with stippled border extending proximally on the dorsal left foot fron a one mm punctum between the proximal phalanges of toes #3 and 4 in a blunted fusiform area of approx two square CM", or identify a "finely papular red rash dorsal L ft, see figure" and sketch it., and be ready for the next pt while efficiently communicating it to the MD, as it did last week. Can't wait for computers.

 

[MedicPrincess]

SOAP and CHART can be confusing sometimes even though they have been standard in medecine for at least 100 years.

OH!!! SO Rid invented the SOAP and CHART method did he?

I use the narrative tell the story version. But it seems to come out like SOAP only without the leading letters.

 

[lightsandsirens5]

Can't wait for computers.

You can say that again!