Notes

Outline

EMS Reports: Writing the Narrative Author: Lt. Andrew L. Bluestein

EMS Reports: Writing the Narrative Objectives: To understand the “SOAPIER” Method of narrative writing. To be able to use the “SOAPIER” method of documentation to record all patient information on EMS calls.

EMS Reports: Writing the Narrative Motivation: To create the most accurate, organized, and complete patient record possible. A complete narrative is the best tool for including all important patient information that might need to be recalled by the Department, or an individual provider at a later date. A complete narrative assists in providing accurate data for Departmental and State analysis of patient care issues.

EMS Reports: Writing the Narrative Overview: A complete and accurate narrative should be completed on any patient where you have provided medical care; including assessment, treatment, or transport. One of the best methods of completing a detailed and accurate narrative is the “SOAPIER” method.

EMS Reports: Writing the Narrative “SOAPIER” Method  S ubjective  O bjective  A ssesment  P lan  I mplimentation of Protocol  E valuation  R evisions

EMS Reports: Writing the Narrative Subjective What did the patient or family tell you?

EMS Reports: Writing the Narrative SOAPIER : Subjective Chief Complaint (quote if possible) “SAMPLE”  S ymptoms  A llergies  M edications  P ast Medical History  L ast Meal  E vents

EMS Reports: Writing the Narrative SOAPIER : Subjective “O,P,Q,R,S,T”  O nset (When did it start?)  P rovication (What makes it worse / better?)  Q uality (what kind of pain is it?)  R adiation ( Does the pain go anywhere?)  S everity (How bad is the pain?)  T ime ( How long has this been going on?)

EMS Reports: Writing the Narrative Objective What do you see?

EMS Reports: Writing the Narrative SOAPIER : Objective Age, Sex, Weight General Condition of Patient Level of Consciousness (GCS) Position Patient is Found Mechanism of Injury

EMS Reports: Writing the Narrative SOAPIER : Objective Physical Assessment Head Chest Abdomen Lumbar Spine / Pelvis Extremities Vital Signs

EMS Reports: Writing the Narrative SOAPIER : Objective Head Head, Eyes, Nose, Face, Neck Skin Color, Temperature, Moisture Pupils (PERLA- pupils equal and reactive to light accommodation) Airway Assessment Include Pertinent negatives (JVD, Tracheal Deviation)

EMS Reports: Writing the Narrative SOAPIER : Objective Chest Thorax – Front and Back Deformities, Discoloration Lung Sounds – Type, Location, Quality, Equality Heart Sounds Pain – Location, Reproducible

EMS Reports: Writing the Narrative SOAPIER : Objective Abdomen Deformity Discoloration, Distention Pain Location by Quadrant Bowel Sounds Tenderness Lumbar Spine / Pelvis Deformity, Discoloration Pain Location Position of Patient

EMS Reports: Writing the Narrative SOAPIER : Objective Extremities Deformity, Discoloration Edema Neuro Check – Sensory Function, Motor Function, Distal Pulses Vital Signs Blood Pressure – Position, Orthostatics Pulses – Rate, Regularity, Carotid-Femoral-Radial Respirations – Rate, Rhythm, Depth, Difficulty

EMS Reports: Writing the Narrative Assessment What do you think is going on ?

EMS Reports: Writing the Narrative SOAPIER : Assessment Your Impression of the Patient’s Condition and Degree of Distress Site Of Injury List Obvious Injuries and “Rule Outs” for Illnesses

EMS Reports: Writing the Narrative Plan / Implementation of Protocol What did you do ?

EMS Reports: Writing the Narrative SOAPIER : Plan / Implementation of protocol Your Actual Field Intervention and/or Advice Given Prior to Refusal Include Treatment Times, Consulting Hospital, or Reasons for No Consult Include Transport Times, Method, Mode, Priority, and Receiving Hospital

EMS Reports: Writing the Narrative Evaluation / Revisions What happened after you did it ?

EMS Reports: Writing the Narrative SOAPIER : Evaluation / Revisions Patients Response to Any Intervention Change in Patient’s Condition En Route Include Revisions and Reasons for Omissions of Treatments According to Protocol

EMS Reports: Writing the Narrative Summary: Recording complete and accurate patient information is one of the most important components of pre-hospital care.

EMS Reports: Writing the Narrative Summary: A complete Narrative is a providers best tool to record all important patient information. “SOAPIER” is one of the best methods to create a complete, accurate and informative narrative.

EMS Reports: Writing the Narrative Acknowledgments: Photos by Michael Heller, from www.911pictures.com Photos by Craig Jackson, from www.inthedarkphotography.com Photo by R. Lawrence Porter, from www.911pictures.com