The Dope on SOAP charting

For some reason, SOAP charting seems to get people confused. It is an easy way to break down the information you are presenting if you do it right. The trick is to tell the story that allows the history to be separate from the observable findings. Why? Because what dispatchers and patients and families tell us, may or may not be what's actually going on.

S Subjective - things people tell you. 

• Called to scene for a...
• pt’s chief complaint is …
• pt’s s/o states...
• SAMPLE History
• OPQRST
• Medications/Allergies
• Medical History

O Objective - things you observe

• On arrival pt appears...
• Pt/Scene appearance
• AOX4 or AVPU
• Vital Signs
• DCAPBTLS

A Assement - what might be going on COPD vs CHF
chest pain protocol

• hypoglycemia
• hyperglycemia
• abdominal pain

P Plan - what you plan to do about it.

• o2 15L NRB, 12 lead, monitor, expedite transport, ALS ...