We use C.H.A.R.T, no S.O.A.P. here.

[MMiz]

Initially our company allowed the EMT to choose their favorite method, CHART or SOAP. Now we're all required to use CHART. I'm wondering what everyone else uses.

My favorite is the requirement of "Pt secured with straps x3, rails raised". Everyone writes it but I never thought we'd be in a society to worry about such trivial things. I learned in EMS nothing is trivial... and my QI supervisor seems to agree.

 

[ffemt8978]

Washington state actually requires us to use the SOAP format. At my previous department, our reports were written in the exact same manner that we gave our run reports.

I have two problems with the SOAP format, though. The first is that there can be a lot of information repeated (in a different way) between the S and the O portions. Also, our medical director wants us to enter a very specific assessment. Instead of RUQ Abdominal Pain, we have to put the following: Poss. Gall Stones, Poss. Appendicitis, Poss. GI Bleed, Poss. Hepatitis, Poss. Ectopic Pregnancy (females only). My concern with this is getting hauled into court and having a lawyer rip into me about my diagnosis/assessment (don't kid yourselves, assessment can be considered a diagnosis in court).

I asked why the SOAP format was required, and was told so that the hospital can look up specific information when needed. I agree that a standard format is nice, but shouldn't they be reading the whole report instead of bits and pieces?