The S.O.A.P. Note In Problem-Oriented Exams

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Last time, we discussed some principles of the medical history and physical exam, something important to know for those  medically responsible for a group in survival settings.

Few medics will be conducting regular yearly physicals in survival scenarios. Their patient encounters will be related to some medical problem, such as an injury or illness. The reason why a patient is seeing the healthcare provider is known as the chief complaint (CC).

The reason someone seeks medical care is sometimes very obvious and may take little medical skill to ascertain. Why it’s happening is not always as clear. For example, a person presenting to the medic with tremors needs a full neurologic (nerve-oriented) exam, but might not have nerve disease. They could be withdrawing from alcohol addiction or suffering from exposure to cold.

Let’s say someone has a problem with their arm. When it comes to an injury in a specific area, a simple general method of evaluation is known as D.O.T.S.:

D: Deformity. Is there an abnormality of the area compared to the same place on the other side of the body?

O: Open wounds. Has the skin been breached?

T: Tenderness: Is there a lot of pain?

S: Swelling: Is the area swollen compared to the opposite side?

A problem-oriented exam more efficiently identifies the issue. If you’re evaluating a college football player whose CC is that they hurt their knee during a game, you probably don’t need to perform a full heart and lung exam. If an older person presents to you complaining of leg swelling not associated with injury, however, cardiac causes should be ruled out.

THE S.O.A.P. NOTE

Documentation is important if you’re going to follow a person’s progress long-term in your role as medic. You can’t be expected to remember everything, and a written record helps those who succeed you as group medic. Of course, written records are most manageable if you are staying in place.

The simplest method is called “S.O.A.P.” A SOAP note is concise and only contains necessary information. It can be used for a fast evaluation or, perhaps, to follow the progress of an injury or infection. There are four parts:

S: Subjective: What’s the chief complaint? What other information did the patient give you that’s pertinent to the encounter? Here’s an example: A raccoon is biting my foot! That foot, right there.

O: Objective: What physical signs of a problem did you uncover on physical exam? Multiple foot puncture wounds  attached to the teeth of a live Raccoon?

A: Assessment: What is your impression of what’s wrong with the patient? Raccoon bite.

P: Plan: What you are going to do to deal with the problem? Remove raccoon. Clean and dress wound. Make Daniel Boone hat.

It’s not always that simple, but it’s concise and accurate. The chief complaint may require you to get and document more information, such as:

  • Onset: When did the CC begin?
  • Duration: How long has the CC been going on for?
  • Alleviating and Aggravating factors: What makes the CC better? Worse?
  • Radiation: Does the CC move or stay in one location?
  • Time: Is the CC worse (or better) at a certain time of the day?
  • Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC?

In any case, the S.O.A.P. note is the best way the group medic can have a short, concise written record to which they (or their successors) can refer.

In future articles, we’ll discuss more about aspects of the medical history and physical exam.

Joe Alton MD

Joe Alton MD

 

Learn more about the off-grid history and physical, and 200 other medical topics, in the award-winning 4th edition of The Survival Medicine Handbook, available in black and white at Amazon, and in color and spiral-bound versions at store.doomandbloom.net. And don’t forget our entire line of quality medical kits and individual supplies for the serious survival medic.

Hey, don’t forget to check out our entire line of quality medical kits and individual supplies at store.doomandbloom.net. Also, our Book Excellence Award-winning 700-page SURVIVAL MEDICINE HANDBOOK: THE ESSENTIAL GUIDE FOR WHEN HELP IS NOT ON THE WAY is now available in black and white on Amazon and in color and color spiral-bound versions at store.doomandbloom.net.

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