SOAP is another one of those EMS acronyms that has endured through the years. I was taught the SOAP format in my EMT class 20 years ago and I’m still teaching it to my EMT students today.
SOAP reporting has a bunch of things going for it. It’s simple, it’s universal, it easily adapts to a multitude of situations and its feels familiar, because it’s the order your brain naturally recalls a memory of something that happened.
If there is one major limiting factor to SOAP it has nothing to do with its design and everything to do with its use. When you were in EMT school we drilled you on the importance of accurate and complete documentation. We frightened you with ideas about the legality, confidentiality and permanence of your medical reports.
We worked hard to impress upon you the importance of your reporting and, like most, you probably took these lessons to heart. All of these scare tactics might have given you the idea that your medical report is a serious and formal necessity. Serious yes. Formal … no, not always. In fact, in the case of verbal hand-off reports and even standard report narratives (to a lesser degree), I’d argue that rigid formality works against you.
If you want your reports to shine, especially your SOAP format reports, you need to drop the rigid, robot-like formality. What I want you to get from this unconventional review of how to use SOAP is this: you can adapt the format. You can mix it up. You can play with it. SOAP is our tool. We can use it or disregard it in the ways that we see fit.
From now on, I want you to think of soap as your way of answering these four questions:
What did you find?
What do you think?
What did you do?
Let’s look closer at the four elements of SOAP charting and talk about where you may want to stick to the plan and when you may want to adapt it.
S is for Subjective (Pssst, It’s also for Story)
In class, you learned how to differentiate between subjective and objective information. Then you were told to put all of your subjective information in the first part of your report. Well, yes … most of the stuff that should come first in your report will be subjective information. A brief introduction of the patient and the who, what, where and how of the event will comprise the body of your “S” segment.
But far more important than making sure that your report begins with a listing of subjective information, make sure your report begins with a useful story. In truth, when the ER staff is listening to your report or reading the details of the call, nobody really cares if the information is appropriately categorized and separated by subjective and objective data. People care that it makes sense, is well organized and tells the story of what happened.
I include a bunch of arguably objective data in my “S” category. The patients age for sure. A detailed description of the mechanism of injury. Where they were found on scene. A run down of pertinent injuries. All of this information comes at the beginning, not because it’s subjective but because it tells the story of what happened. Tell a story.
Things commonly found in my story include the patients name and age, their chief complaint, mechanism of injury or nature of illness, the what, where, when and how details of the call and an OPQRST when applicable. I’ll also throw in medications and medical history if they are pertinent to the chief complaint. (I give a comprehensive history and med list at the end.)
Let’s look at two actual story samples from reports I’ve written in the last year. This is exactly as the information appears in my patient care report. I was not aware that I would be publishing these narratives when I wrote them.
Here’s a story I told about a woman who had an unusual syncope type event at a party:
Medic 27 responded emergent on a 39 year old female who had a syncope from the standing position. Patient reports that she was at a party when she began to feel nauseous. Walked into back room and then passed out on floor. Witnesses report patient slumped forward on to a couch and then slid backward to a carpeted floor. No obvious head or neck involvement and no significant traumatic mechanism. No seizure type activity noted. Patient also reports that she recalls waking up on floor, feeling cold and shivering. Patient moved to bed with assistance. The patient denies pain in head, neck, chest or back, shortness of breath, headache, vomiting, blurred vision, numbness or tingling in extremities and localized paralysis. Does report mild dizziness and ongoing weakness. A bystander called 911 for assistance.
Notice that I describe the mechanism of her fall and some objective demographics, not because they belong with subjective information but because they fit with the story.
Here’s a sample car accident “S” category story. Notice there are a slew of objective details in this one.
Medic 27 responded emergent to a motor vehicle accident. Upon arrival, contacted a 53 year old female, restrained driver of a four door, mid- size vehicle struck from the rear. Immediately following the event the patient reports experiencing tingling in her neck radiating up into the occipital region. The patients vehicle was traveling approximately 5 MPH stopping for a light. Struck in rear drivers side quarter-panel by another vehicle then came to rest. The primary forces in this collision were rearward to the drivers side. Windshield and steering wheel intact. Headrest height appropriate. The patient does not report striking the interior of the vehicle. The vehicles passenger space and roof remained intact. The vehicles airbag system did not deploy. The patient denies loss of consciousness before or after incident, pain in head, neck, chest or back, shortness of breath, use of alcohol or drugs, headache, nausea, vomiting, dizziness, numbness or tingling in extremities and localized paralysis. A bystander called 911 for assistance.
O is for objective (Get your CSI game on)
Now it’s time to get technical. The objective portion of the report is the time when you state your case and tell everyone the stuff you found during your assessment. It’s time to become the CSI investigator and talk about your investigation and you findings.
This will tend to be almost entirely objective information, however, don’t be scared to throw in the occasional subjective tidbit if it helps to paint your picture. “She thinks this bruise may be old.” or “His ankles are always a bit swollen but not this much.” If a subjective addition adds to the picture, include it.
When telling my objective story I tend to start with the level of consciousness and skin signs then move straight into a head-to-toe report of pertinent findings. Remember that pertinent information can be positive findings (i.e. Coarse ronchi in the upper chest bilaterally.) as well as negative findings (i.e. Abdomen and pelvis were unremarkable to trauma or abnormality.)
For a look at a sample “O” section from a report, lets revisit our syncope patient:
Upon initial contact, patient laying in bed in bedroom. Alert and oriented to name, place, time and event. Skin warm and dry with normal color and tone. Mild muscle tremors (shivers) in arms and legs. Patient does report feeling cold. Head normocephalic without abnormality on visualization or palpation. Neck midline and intact without pain on palpation or movement. Thoracic, lumbar and sacral spine intact without pain on palpation or spontaneous movement. Chest intact with equal expansion, unremarkable on visualization and palpation. Lung sounds clear and equal bilaterally with normal tidal volume. Breathing pattern normal. No odor on breath noted. Abdomen soft, non- tender, atraumatic and unremarkable on visualization and palpation to all quadrants, without masses or rigidity noted. Pelvis and hips stable and intact without pain or crepitus on palpation anterior or lateral. Incontinent to urine. Legs and knees intact and atraumatic. Arms are intact and atraumatic. No language barrier existed between patient and providers.
Patient’s pupils equal, round and reactive to light. Patient does not present with observable perseveration, short or long term memory loss or confusion. Major motor neuros intact. Gross sensory assessment intact with normal sensation throughout. Assessment revealed no abnormal neurological findings. All observable neurological assessments remained unchanged after transport to hospital.
Note at least one example of subjective information bleeding into the O portion of the report. (Feeling cold.) You’ll also notice that I divided out the neurological exam on this call because it was a neurological event and called for a more detailed assessment.
A is for assessment (Not physical assessment but what you think.)
Now it’s time to tell them what you think is going on. Just say it. I know, I can hear the war cry of the insecure EMT already, “But we don’t diagnose!” Of course you don’t. Even if you did provide a diagnosis, it wouldn’t matter. The doctor documents a diagnosis at discharge, not you. He won’t let you write in that blank even if you ask nicely. Everyone knows your not providing a diagnosis. Now drop that ridiculous concern and tell everyone what you’re thinking.
Think you know exactly what’s going on? Say it. Do you have it narrowed down to three possibilities? Say them. (And then discuss it with the staff.) No idea what’s going on? Say it! (And then ask everyone what they think.)
P is for plan. (This is what I did.)
Some of your treatments will be obvious. No need to belabor the high flow oxygen in your verbal hand-off report if everyone can see the mask over the patient face. But don’t forget about how the patient responded to positional changes and interventions like epi-pens, fluid challenges and glucose paste. In my written reports I detail every intervention. If you don’t document it, you didn’t do it.
Here’s the plan portion of my report from our syncope, rule out seizure at the party:
Patient transported non-emergent to Aurora Medical Center emergency room. Patient transported without change in status or level of consciousness. Patients treatment plan included full secondary assessment, detailed neurological examination, vital signs, cardiac monitoring, pulse oximetry and supplemental oxygen. Following hand off report to staff, patient left in hospital bed with rails up and staff in attendance.
You’ll notice that I always finish with the final disposition of the patient. I’ve documented that the patient has been left safe and in the hands of a higher medical authority. You may also wonder why I use no abbreviations. I generate my reports on a computer that draws from my own template. I don’t use abbreviations because the computer is generating most of the text for me. I created the original template without abbreviations. When I am documenting care long-hand, I use plenty of abbreviations.
Above all, when your giving those verbal reports try to stay informal and tell the story in an organized way. When your writing your report, let the information flow from the story of the call to the findings then the actions and the results. Don’t feel chained by the structure of the SOAP format, “I can’t write that yet. It’s not objective.” It’s called a narrative for a reason. You’re the narrator. Have fun. I wish you success.