This document provides guidance on effective medical documentation using the SOAP note format. It discusses the goals of documentation, including writing consistently, comprehensively, and in a legally defensible manner. It then covers the components of the SOAP note format, with subjective (S) covering patient-reported information, objective (O) focusing on clinical observations, assessment (A) stating the patient's conditions, and plan (P) outlining treatment. The document emphasizes writing objectively and avoiding judgment.

1. SOAP Made Easy
Steve Cole
Paramedic, CCEMT-P

2. Revision information
 Last modified 01-20-05
 For more information on this or other
presentations, contact:
– Steve Cole
– rcole@adaweb.net
– colemedic@hotmail.com

3. Goals
 Write consistent and comprehensive
documentation of patient care contacts.
 Write in a form acceptable through out the medical
industry.
 Write charts in a legally defensible way.
 Write charts that demonstrate indications,
responses, and other pertinent information behind
interventions we do.
 Write charts that accurately tell the impact of EMS
on any pt contact.

4. Basic concepts of documentation
1. BASIC "RULE" OF
DOCUMENTATION:
"IF YOU DIDN'T WRITE IT, IT DIDN'T
GET DONE!"
2. THE PROFESSIONALISM OF THE
REPORT REFLECTS ON THE
PROFESIONALISM OF THE WRITER.
3. DOCUMENT THE SAME WAY EACH
TIME .

5. "The best protection from liability is
good pre-hospital care."
"The best protection in a malpractice
proceeding is good documentation."

6. Why Document?
 Professional responsibility
 Legal protection
 Regulatory standards
 Reimbursement

7. The PCR as a legal document
 “Business Record”. We are in the patient
care business, it is a record of our business.
– Discoverable in court.
– Reflects directly on the credibility of the author.
 Refreshing of memory of testimony

8. Barriers to Good Documentation

9. Educational Emphasis
 Covered Briefly in initial training.
– Only a few pages in most text books.
 Not tested, reviewed
 Inconsistent training methods
 Different Styles, all correct.
– Its not a “Skill Station”

10. Blind leading the blind
 Usually taught “on the Job”
 Sometimes those who are teaching are
teaching bad habits based on
misconceptions, out dated information, or
outright bad information.
 Only corrective action is often for billing
purposes.

11. "Drudgery" vs. Personal Challenge
 Improving documentation skills and
discovering enjoyment in charting requires
personal effort, study, and practice.
 Self esteem and the desire to excel can
motivate this personal effort, yielding great
personal satisfaction, a sense of
accomplishment, and professional respect.

12. Standards (lack there of)
 Abbreviations
 Permissible errors
 Addendums
 Format

13. Documentation Pitfalls

14. Handwriting
 Handwritten Charts
Concerns:
– Legibility
– Spelling errors
– Reluctance to rewrite
– Poor legibility = perceived
attempt to cover up
mistakes
 Solution: Computerized
Charts
– Legible
– Easy and quick to correct
– Professional appearance.

15. Open Spaces
 Parts of the run form
not completed may be
perceived as laziness
in a court room.
 Time Entries not
completed are most
common.
 Fill in blanks on chart
forms
– “n/a”

16. Vital Signs
 Minimum of one
complete set for every
patient
 Two sets preferred.
 One early on, one
prior to release.

17. Relevant vs. Judgmental ?
 Profanity.
 Criminal Behavior
prior to call.
 Misc. Statements of
bystanders.
 Prior EMS Contacts.
 Memory Recall

18. Dotting the I’s
 Document the clinically significant details
 Sign every entry
 Write neatly and legibly
 Use proper spelling, grammar, and
appropriate medical phrases
 Document in blue or black ink and use
military time

19. Crossing the T’s
 Use authorized abbreviations
– Department approved abbreviations
 Record the patient’s name on every page
 Chart promptly
 Chart after delivery of care

20. Other Minutia:
 Document exact quotes
 Eliminate bias from written descriptions of
patients
 Do not tamper with records
 Correctly identify late entries
 Record only accurate information (mg , etc)

21. Legal
 Do not omit significant information from the chart
 Correct mistaken entries properly
– Initial, single line
– 3 mistakes total per ACEMS standards for written
documentation
 Do not rewrite the record
 Do not lose or destroy medical records (HIPAA)
 Do not add to the notes of others

22. LEGAL
 ALWAYS BE SURE YOUR RECORD
DOES NOT CONTRADICT ITSELF!

23. The importance of Perception
 Often Legal action is taken because of Act of
Omission, no Commission.
 We are (most often) sued because of something
that was not done.
– We didn’t treat a condition
– We didn’t provide transport
– We didn’t take time to…
 Many times this results in a underlying perception
that we didn’t care enough to do our job.

24. The importance of Perception
 It is important that our patient chart clearly
shows that we were not just bystanders to
the patients condition, but we took an active
part in being a pt advocate.
 This changes the perception from us being a
lazy medic who didn’t take the time to
transport (or treat) the patient to a caring
individual who tried to take care of a patent
but the patient (or situation) prevented it.

25. The importance of Perception
 Examples:
– Refusals:
» “Transport was clearly offered”
» “Informed refusal of care obtained, risks explained
including death, and pt declined”
– Getting Family, case worker, etc. involved.
– Advising the patient of alternative resources for
getting assistance.
– Calling ahead to hospital to advise them of
patients ETA if arriving via POV.

26. Patient Confidentiality

27. Patient Confidentiality
 Most common wrongdoing of EMS
 “What happens on the job stays on the job!”
-Be careful of what you say in restaurants,
elevators, EMS room
 If you have a patient that comes to the
station requesting a copy of PCR you must
receive written request, follow departmental
policies, etc.

28. Exceptions for release of data:
 “need to know”- other providers at risk
 Assault & battery, rape, abuse, etc.
 Third party billing for medicare/medicaid
 Proper subpoena
 Appropriateness of release of information
 Still need to follow policy.

29. Invasion of Privacy
 When you break confidentiality agreement
releasing information without patient
consent
– Discussing someone's STD with others
– Implying someone was DWI
– Discussing Domestic battery cases

30. What is HIPAA
 Health Insurance Portability and Accountability Act
– Est. in 1996 by The Centers for Medicaid and Medicare
(CMS)
 This is the federal regulations that are now put in place to
protect protected health information (PHI).
 Also sets forth standards for electronic health care
transactions.
– If you ask me this is like the standard patient confidentiality
practices we’ve all been taught on crack!!??

31. What is PHI
 Protected Health Information
– ANY information that can ID that pt to a
medical problem.
– SSN, DOB, Name
– Address
 Incidental Disclosure
– Bystanders
– Public View
– Radio

32. Goals of HIPAA
 Limit the non-consensual use and release of
private health information
 Give patients new rights to access their
medical records and to know who else has
accessed them
 Restrict most disclosure of health information
to the minimum needed for the intended
purpose
 Establish new requirements for access to
records by researchers and others

33. Goals of HIPAA
 Establish new criminal and civil sanctions for improper use or
disclosure of PHI
– Civil penalties for inappropriate disclosure are $100 per
episode and no more than $25,000 per calendar year.
– Inappropriate disclosure of PHI can be punished by $50,000
fine and up to one year in the pen.
– Obtaining PHI under false pretenses can be punished by
$100,000 fine and up to 5 years in the pen.
– PHI disclosure for commercial use, personal gain, or
malicious harm can lead to $250,000 fine and up to 10 years
in the pen. (Sorry, you can’t say Bob Dole will die before his
term is up again)
» These fines and assessments have been published but
there will be a whole separate rule published eventually
that outlines and describes the infractions and fines
further.

34. HIPAA
 Three Approved reasons for HIPAA
Disclosure
– Legally mandated reporting
» Subpoena
– Operational Uses
» Educational Uses
» QA/QI
– Transfer of Care
» FULL DISCLOSURE

35. HIPAA Compliance
 HIPAA Training
 Safeguards
– Policy
– Physical/Electronic Access controlled
 Notification of Privacy Procedures to pt’s or
family.
– Good Faith Paperwork
– Signature forms
 ALL PATIENTS YOU COLLECT PHI ON!

36. Types of charting

37. Charting systems
 Effective and efficient charting has been an
issue to medicine throughout history.
 Numerous methods of charting have
evolved over time.
 More are evolving every day.

38. Narrative Method
 A diary or story like approach to the
recording of patient care
 Are more efficient if used in combination
with flow sheets for recording some
repetitive data

39. Narrative Method
Advantages:
 Good for triage systems, quick entries
 familiar to most nurses
– can be easily combined with other methods
» “P” in SOAP

40. Narrative Method
Disadvantages:
 lack of structure
 task oriented and time consuming
 information may be difficult to retrieve
 does not always reflect critical thinking,
decision making and analysis

41. CHART Method
A Problem Oriented method of charting
 C: Chief Complaint
 H: History (AMPLE)
 A: Assessment
 R: Rx (Treatments done)
 T:Transport (Events during transport)

42. CHART Method
Advantages:
 Good as a format for verbal reports,
 Simple to remember
Disadvantages:
 Is not accepted outside of the EMS community
 Does not take into account other factors beside pt
care (like scene survey, etc)
 Not as comprehensive as other forms.

43. Charting by exception
 Includes flowsheets, documentation by
reference to standards of practice, protocols,
a nursing data base, nursing diagnosis based
care plans and SOAP progress notes

44. Charting by exception
 Basically the Idea of charting only
exceptions to the norms
If the lungs are clear and equal, then it doesn’t get
charted.
 Requires a defined set of “norms” to
function correctly
 Gained popularity but is now disappearing.

45. Charting by exception
Advantages
 Quick and easy
 Very little time involved.
 Provider friendly.
Disadvantages
 can require duplication of charting
 Does not accurately paint a picture.
 may impact reimbursement
 Poorly defensible

46. Computerized Charting
 One of the strongest trends in EMS
documentation throughout the US and
Canada.
 Very common in the larger Systems in this
area.

47. Computerized charting
 Advantages
– Legible records
– Readily available records
– (allegedly) Improved productivity
– Reduction in record tampering
– Better QA process
– Better Data Collection
– Reduction in redundant documentation
– Clinical prompts, reminders, and warnings

48. Computerized charting
 Disadvantages
– Unfamiliar to users
– Lack of portability
– Problems with security and confidentiality
– Disruptive computer downtime
– Size of the record
– Erroneous acceptance of information
– Limitation of format

49. Computerized charting
 Disadvantages, cont
– Resistance
– Cost
– Legal Defensibility from poorly written
narratives
– THE PT DOES NOT FIT THE COMPUTER
PROGRAM

50. SOAP charting
A problem oriented charting method
 Subjective data
 Objective data
 Assessment
 Plan

51. SOAP Method
 Has been expanded in NURSING to include
– SOAPIE
» add Interventions
» add Evaluation
– SOAPIER
» add Revision

52. SOAP Method
Advantages:
 well structured
 reflects the care process
 easier to track particular problems for QI
 can be used effectively with standard care plans
 frequently used in the integrated plans
 Is used through out the medical and billing
community.

53. SOAP Method
Disadvantages:
 requires rethinking documentation process
 can be redundant
 not the Quickest
 has met some resistance due to effort
needed to document correctly.

54. At Ada County EMS we have
implanted a computer charting
system , but we still write a
SOAP note with in the system.
This gives us good defensible
charts while retaining data
management and QA functions.

55. WHAT IS THE
SOAP?

56. SUBJECTIVE
 EVERYTHING you find out about the pt
from something other than direct
observation/Assessment
 Information from the pt.
 Information from the PD
 Information from the Chart (Exception:
some diagnostics)
 Information from other medical providers
prior relating to care prior to your arrival

57. Dispatch Information
 Keep separate from main body of the SOAP, still
important.
 Very important with multiple pt’s.
 “Medic 1 dispatched to MVC. On arrival
presented with multiple patients, this is pt 2 of 4
seen by this unit.”
 Be sure you coordinate with other providers so
your numbers match up.
 Good place to document delays, wrong directions,
etc.

58. S: “once upon a time”
 Your opening lines can break a subjective
– Pt. Age, C/C or reason why they were unable to
present one.
– Followed by Secondary Chief complaints.
 “Pt is a 31 y/o male with c/c of lower back
pain secondary to fall. Pt also complains of
SOB, Nausea, and dizziness”

59. S: Quotes
 Pt States: Exact verbage
 Pt reports: summery
 Guess what ... if the patient has a potty
mouth and this disposition or information
is important to the situation, go ahead and
include the quotes, but don't forget
quotation marks!

60. S: OPQRST
 Very Important when describing any type of
Pain.
 Can be used very effectively for other types
of discomfort (chest pressure, tightness, etc)
and complaints (nausea, vertigo, etc)

61. S: “OPQRST” Pain Questions
– Onset - when start, sudden or gradual. Activity at
onset.
– Provoke - position, movement, local or general
– Quality - sharp, dull
– Radiating - if so, from where to where
– Severity - mild-moderate-severe or scale of 1-10
– Time - how long, continuous or intermittent, worse
or better. Crescendo pattern.

62. S: Previous episodes
 Prior episodes, what brought it on?
 Seen By an doctor?
 Self or prescribed treatment (w/ or w/o
success)
 Crescendo pattern?

63. S:Pertinent positives and
negatives
 Depends on c/c
 Very important
 Can protect you or open you up
 Common ones : Chest discomfort, SOB,.
N/V, Near syncopal episodes, dizziness,
previous episodes.

64. OBJECTIVE
 Just the facts mam”
 Clinical, objective,
non judgmental
 Think scientific
 Think MR. Spock as a
paramedic.

65. O: VEHICLE
DAMAGE/SCENE SURVEY
 General hygiene of area
– Food in fridge, Garbage overflowing, fecal
matter on floor or in bed.
 Vehicular damage (or lack there of)
– Points of impact, distance from road,
windshield starring, steering column damage,
etc.
 Pill bottles, drug paraphernalia
 Crowd/safety issues.

66. O: The Pt
 Who is with the pt
– PD, Nurse at bedside, family, bystander, little green
men
 Position of the pt?
– Recumbent, supine, simi-fowlers, standing
 Interventions in effect?
– O2, IV ,C-collar, Manual C-Spine,
– “Stare of life”
 What is the pt doing?
– Walking, Running, Fighting, yelling, gurgling,
tripoding

67. O: LOC
 LOC is the most important descriptor in the
primary survey, as it will be examined closely in
DWI cases, mental holds, criminal prosecution,
REFUSALS, etc.
 Conscious , alert, oriented to person , place, time
(x3)
 Cooperative
 Mental affect, demeanor
 Short vs long term memory
 Cognition

68. O: Primary Survey, rapid survey,
etc…
Examples
 LOC: Mentation, described before
 Airway: Clear, snoring
 Breathing: Labored, Non labored, retractions,
grunting, speech dyspnea, audible wheezes
 Circulation: Skin pallor, distal pulses quality
 Disability: Mini nuero, left sided deficits, slurred
speech, unstable gait, moves all ext well.

69. O: Head to toe
 HEENT:
 NECK/BACK:
 CHEST:
 ABD:
 PELVIS/LOWER EXT:
 UPPER EXT:
 NEURO: Detailed Neuro (optional)

70. O: Diagnostics
 Blood Glucose: State source (IV stick,
capillary blood)
 Pulse OX: before and after O2 or BVM,
neb, etc
 EKG/ 12 lead (if you are qualified to read,
may be cosigned by medic )
 Temp: Oral, axillary, rectal, etc
 ETCO2.

71. O: Vital Signs
 Vital signs may be recorded in “O”, “P”. Or
elsewhere in chart depending on PCR layout.
 Vital Signs Record: 2 Sets Minimum; "serial" VS;
Palpated vs. auscultated B/P VS: palpated B/P
documentation; respiratory rates (and techniques
for correctly counting them).
 Documentation of Orthostatic ("Postural") VS
changes: using stick figures to indicate the
patient's position during VS measurement.

72. Assessment
 Field Diagnosis
 No “red swollen deformed extremities”
– Call a Fx a Fx!
 R/O, Rule Out: Cop Out
 Possible, probable etc are looked down on for
billing purposes, but may be used if you don’t bill.
– OK as a supplement to a DX “Altered Mental staus ,
probable herion overdose”
 Chronic problem that got worse? : “exacerbation
of”
 VS.
 Try to have at least two diagnosis

73. Assessment continued
 Syndromes are a collection of predictable
symptoms from a common cause;
– Hyperventilation syndrome
 Diagnosis of exclusion
– Dx made only after all other things have been
ruled out. Common pitfall, be very careful
– Alcohol intoxication,
– Anxiety, Psuedo-Seizure
– Muscular neck pain

74. A: Common assessments
 Soft tissue injury secondary to fall
 Pleuratic pattern Chest wall pain
 Ischemic pattern Chest pain
 Syncope/near syncope of unclear origin
 TIA , CVA with left sided deficits
 Multi system trauma
 Hypoglycemia (may add resolved)
 Post Seizure, Active Seizure , Status epilepticus
 Altered Mental Status- Probable Heroin Overdose

75. The PLAN
 Chronological detail of pt contact beginning with
on scene. Use time notations.
– Exception: may place pert . Info to call that occurred
and caused a delay to pt contact, like dispatch error, ect.
– “(2030) On scene, contact delayed secondary to scene
sfety issues. EMS staged.
– “(2040) Pt contact and assessment”
 Use 3rd person.
 Both Subjective and Objective.
 Itemize

76. P: Interventions
 Time?
 What?
 Who?
 How Much?
 Response/adverse effects? OBJECTIVE and
SUBJECTIVE.
 Why?
 “(2031) Oxygen applied by S. Cole for SOB at 10
LPM NRB mask with pt reporting some relief. Pt
work of breathing decreases.Chest pain decreases
to 4/10.”

77. P: Reassessments
 Document reassessments to justify doing or
with holding interventions.
 “(2035) Reassessment finds increased work
of breathing, decreased tidal volume, and pt
unresponsive. Sats decreased to 66%”
 “(2035) NRB mask changed to PPV via
BVM with 30 fr. OPA by S. Cole with Sats
increasing to 90%.”

78. P: Critical Events
 Critical events that do not fall into other
categories are still documented
chronologically.
 (2038) RN on location presents EMS with a
valid Comfort One DNR (#xxx).
 (2038) Pt’s Mother on scene, becoming
violent , restrained by PD, requiring EMS to
relocate pt to MICU”

79. P: refusals
 “Risks explained”
 “transport options discussed”
 “Pt deciles transport”
 “Informed refusal of services”

80. P: End of call
 Transfer of care: “Report to XXX” “Pt left on
scene with PD.
 Belongings: “all paperwork, purse (with
undisclosed contents) and other belongings at
bedside (to EMS staff, etc.).”
 Pt condition on d/c: “Pt alert , oriented, calm, and
in no apparent distress” “Pt tearful, tachypniec,
and yelling at EMS on clearing”.
 HIPAA and/or billing completed?

81. P: After notes
 Itemizing of :
– Drugs
– ET attempts
– Shocks
– Etc
 Other facts.

82. Special Situations: Crime Scenes
 You are writing a MEDICAL report, not a
criminal investigative report.
 Don’t neglect good documentation of pt
medical condition for documentation of
criminal events.
 That said, don’t neglect events pertinent to
pt’s medical condition if they involve
criminal activity.

83. Final thoughts
 Use protocols, articles, medical text books
to be sure you cover all points in a medical
complaint
 Use medical dictionaries frequently
 Document in third person.
 Use a set format, each and every time that
covers all facets of pt care.