The A&P of SOAP

The A&P of SOAP

Jacky Vaniotis, RN, NREMT-P

In previous issues of this journal, we have looked at documenting our subjective and objective findings on our run sheets. We have looked at how important it is both to get a complete history from the patient and to completely document all the information that we obtained. We have also looked at the importance both of performing a thorough assessment of the patient’s physical condition and surroundings, and of documenting all that we found. In this issue’s article, we will continue the series by looking more closely at the last two pieces of the SOAP format, the Assessment and the Plan.

To a new EMT just learning the SOAP charting method, the “A” always seems to cause confusion. The “A,” of course, represents Assessment, and the new EMT will say that the patient assessment is what we already did when we were obtaining our subjective and objective information, so, they wonder, why do we have another area, this one actually called “Assessment?!” But eventually most of them come to understand that the “A” in SOAP is really where we ask ourselves what we think is wrong with the patient based on the assessment we just did. The “A” is what we’re treating him for, and is written on the run sheet in the box marked “Patient’s Suspected Problem.”

The “A” can be simple: possible MI, asthma exacerbation, GI bleed, multi-system trauma. Whatever the Assessment, or Patient’s Suspected Problem is, however, it needs to correlate with the assessment findings.

There is nothing wrong with an “A” that is virtually identical to the patient’s chief complaint, if that is what we’re treating the patient for. A patient who calls for shortness of breath and is treated with albuterol is being treated for his shortness of breath. We can write that he’s having an exacerbation of his asthma or his emphysema, but we are also correct if we simply write that his suspected problem is shortness of breath. Similarly, if a patient falls and injures her ankle, we can write that her suspected problem is an ankle injury, or, if we really believe there’s a fracture and have backed it up previously with our subjective and objective findings, we could write “fracture,” but in either case, we are treating the patient for the ankle injury.

When we run into trouble is situations in which a patient has a chronic medical condition and calls us for something perhaps only remotely related. Take, for example, a patient with Parkinson’s who falls and sustains some injuries. His “A,” or suspected problem, for this call is not his Parkinson’s itself, but rather the injuries sustained in the fall, even if the fall was due to his disorder. So we would not write “Parkinson’s disease” as our “A,” but “injured hip” or “back injury” or whatever.

The patient might have lung cancer, but if we’re treating him for bronchospasm today, with albuterol MDIs or nebulizers, our “A” is bronchospasm (or maybe shortness of breath), because that’s what we’re treating him for; that’s his suspected problem at this time. It may be that he’s chronically short of breath because of the cancer, but if we’re treating him today for his shortness of breath with bronchodilators, it’s because we believe he has some bronchospasm that we can help with our treatment. The problem today, the “A, “ then, is not the cancer, but the bronchospasm.

One final example: If the patient has been vomiting, is weak, is slightly tachycardic, and has dry mucous membranes, we might suspect his problem to be “dehydration.” We aren’t necessarily in the business of diagnosing the cause of the vomiting that led to the dehydration, but we are treating the patient’s suspected problem of dehydration, with IV access and fluids, so our “A” is dehydration. The vomiting could be the result of any number of conditions that are beyond our scope to diagnose. The bottom line is that we are treating the problem of dehydration, which is secondary to the vomiting, regardless of the cause.

So we’ve completed writing about our assessment findings, both subjective and objective, we’ve determined what we believe to be wrong with the patient and written that down; all we have left to document is the plan of care. For those folks who say they like to write their notes in narrative form, this will be good news, because here is where we do write everything in the order that we did it, much like a narrative description. Our Plan starts from the moment we approach the patient, and ends when we transfer care to the hospital staff. It includes everything we did, as well as the patient’s response to our treatments. So, for example, if we are treating a child with an isolated extremity injury sustained at school, we might document our treatment plan as follows: “1) initial assessment, 2) focused assessment [the findings of which the reader will have just read] 3) splint right forearm with rigid splint and sling (pulses, sensation and movement present both before and after the splint was applied, 4) elevation, 5) ice, 6) transfer patient to cot (CSM unchanged after transfer) 7) school nurse attempting to contact patient’s parents, 8) transport to hospital (without changes en route), 9) transfer care to staff at ....”

Note that with each part of our plan, we must also indicate the presence or absence of any changes in the patient’s condition, whether better or worse, throughout the entire time of our care. And if the changes indicate a worsening of the condition, we must indicate what we did in response — and how the patient responded to that as well. Many run sheets I’ve seen are woefully deficient on the response to treatment. There might be adequate, or even more-than-adequate documentation of the patient’s assessment findings, and even a thorough plan of care, there is no indication as to whether the EMT’s treatment had any effect. And that, after all, is the measure of whether or not EMS is of any value!

One area of particular concern, from a medical-legal point of view, is with the Maine Spine Assessment Protocol. People very often document that they used the protocol, but not what they found when they did their assessment. It is these findings on which they based their decision as to whether or not to immobilize the patient, and it is these findings on which they would need to base their defense if the patient ended up having had an injury and suing the EMS providers. If EMS doesn’t have those findings clearly documented, they will potentially be relying on months- or years-old recollections when they need to defend their decision. If they have not already clearly described findings from all four parts of the MSAP (reliability, presence or absence of distracting injuries, findings from the sensory/motor exam, and presence or absence of spine pain and tenderness) in their Subjective and Objective documentation, they must indicate them in their Plan. An example of a Plan that includes specific reference to the MSAP would be: “1) Initial assessment with manual spinal immobilization; 2) Rapid trauma (or Secondary) survey; 3) Maine Spine Assessment Protocol (patient calm, cooperative, no evidence of intoxication, alert and oriented; no distracting injuries; hand grasps equal and strong, finger ab/adduction equal and strong, foot strength equal and strong, denies paresthesias, sensation present and equal in all four extremities; denies spine pain, no tenderness to palpation); 4) transport in position of comfort (no changes en route); 5) transfer care to Elizabeth, triage RN in ED.” (Remember that, if all of the above-mentioned MSAP findings were already clearly documented in the Subjective and Objective components of the narrative, they need not be repeated in the Plan component.)

There’s a saying we’ve all heard, and most of us have used in some circumstance or another, that “if it wasn’t written down, it wasn’t done.” Everybody understands that, in theory at least, but often people don’t go far enough. If we didn’t write down that we gave the patient oxygen, there is no way that we can prove that we did, indeed, do that. But if we gave the patient oxygen, and wrote it down, and we didn’t indicate that it brought her oxygen saturation up from 83 percent to 92 percent, or that it caused some relief of her chest pain, or, conversely, that the patient was unable to tolerate the non-rebreather mask and we switched him from a non-rebreather to a nasal cannula, then — did those things happen? Can we remember those things days or weeks or months or even years from now when we might be called on to remember them? Can the hospital care providers, who perhaps were not the ones who took our verbal report, look at our documentation after we we’ve left the hospital, and know that we did attempt to reach the family of our injured child, or that the patient vomited moments after we gave an injection of morphine? We must document not only what we did, but also the patient’s response to our treatment.

No part of the assessment and documentation is less important than any of the others, but they all do hinge on each other. Without doing a thorough patient assessment, we cannot document findings of a patient assessment. Nor can we come up with a well-thought-out “Patient’s Suspected Problem” or Plan of care. And if we don’t document our treatment and the patient’s response to it, we have no way of showing that our care was worth anything more than a taxi ride to the hospital would have been.

In the next, and final, installment in this series on documentation, we will attempt to fine tune our writing by looking at some general thoughts and suggestions. If you have any particular ideas or concerns you’d like to see included or discussed, please contact me at Jacky_Vaniotis@onf.com or through the MEMS office before the deadline for the next issue of this journal.