S.O.A.P. System:
- Subjective:
- PC; Presenting condition information from patient regarding their main complaint.
- HPC; History of the main complaint including:
- Onset, Location, Characteristics, Alleviating and Aggravating factors
- Quality of pain, Radiation
- Duration of symptoms or signs
- Objective:
- Scene and patient observations including:
- Primary Survey
- Vital signs
- SAMPLE History (see below)
- Scene and patient observations including:
- Assessment:
- Focused enquiry of the chief complaint:
- Physical examination
- Inspection
- Auscultation
- Palpation
- Review of systems to develop differential diagnosis
- Patient assessment is an on-going and continual process; officers must manage presenting symptoms as they find them throughout the assessment process.
- Focused enquiry of the chief complaint:
- Plan:
- How you plan to manage these or treatment provided
- Impression
- Immediate and secondary plans
- Results of commencing interventions
- Apply treatment, assess the result and re-assess/manage as required.
- How you plan to manage these or treatment provided
Vital Signs
A vital signs survey is completed to establish a baseline of the patients condition in order to determine time criticality and identify emerging trends. A full set of vital signs should be obtained early and should be repeated at regular intervals as appropriate for patient’s condition.
The following are a list of vital signs, some of which are mandatory in ePCR, others may need to be assessed based upon clinical presentation and scope of practice:
- Pulse
- Respirations
- Pulse Oximetry
- Auscultation
- Blood pressure
- Cardiac monitoring
- Glasgow Coma Scale (GCS)
- Blood Glucose Level (BGL)
- Temperature
Once vital signs have been obtained, an Early Warning Score should be calculated based on the Recognising and Responding to Acute Deterioration guideline, and any patient meeting an escalation level should have appropriate action taken.
Chief Complaint & History Gathering
History gathering is an important skill. Through appropriate questioning and investigation, crucial information may be gathered to assist in patient management. It is very important to be objective so as to avoid tunnel vision.
Develop
your own method of questioning that will assist in producing the information listed below:
Chief Complaint
- Identify main presenting problem.
- Establish Mechanism of Injury in order to identify the potential Pattern of Injury.
- Examples include:
- Weapon type (blunt, stabbing)
- Blade size, type, length (serrated or non-serrated)
- Number and speed of vehicles involved; impact points
- Seatbelts present and/or worn
- Airbags present and/or worn
- Cabin intrusion
- Windshield / headstrike
- Weapon type (blunt, stabbing)
- Gather information to determine treatment priorities and formulate plan for treatment, SAMPLE.
Assess complaints and signs and symptoms using OPQRST mnemonic:
| Onset | Was onset of symptoms fast or slow? |
|---|---|
| Pain | When did the pain start? Was it sudden or gradual? What were you doing when the pain started? |
| Quality | What words would you use to describe your pain? |
| Radiates | Point to the area that hurts the most, where does it go from there? |
| Severity | Use the PAINLOG™ as the determination of severity of pain levels or if PAINLOG™ not available verbally ask pain level e.g. on a scale of 0 - 10, 0 being no pain and 10 the worst pain imaginable, what is your pain level. |
| Treatment / Tablets | What treatment (if any) are you receiving from your doctor/hospital? What tablets (if any) have you been prescribed? Are you taking any other tablets? |
Obtain patients pertinent medical history using SAMPLE mnemonic:
| Signs and Symptoms | What can be seen? What is the patient complaining of? |
|---|---|
| Allergies | Do you have any allergies? |
| Medications | Are you taking any prescribed medication(s)? |
| Pertinent History | Do you have any i.e. cardiac problems / diabetes? |
| Last oral intake | What was the last time food or drink was consumed? |
| Events leading up to... | How and when did it occur? Has it occurred before? |
For Trauma gather information relating to the Mechanism of Injury.
Past Medical History
- May be chronic or acute
- Previous injuries
- Previous operations
- Obstetric/gynaecological considerations
Medications
- Attempt to note which medications the patient is taking.
- May need to be transported with patient for hospital to document.
Scene
- Additional useful information may be gathered from the scene such as evidence of drug use, domestic problems, mental functioning
Key Terms & Links
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