SOAP Report Guidelines for EMS

Adapted from Temple College's "Key Elements of SOAP Report Format."

When I was struggling with the chart-writing part of my training, one of my Field Training Officers suggested that I use the SOAP portion of the run report to "paint a picture." This helped me to focus on describing the call well enough that the reader could see what I saw and hear what I heard. However, make sure you don't include things that are irrelevant or judgmental. Thanks, Steve!

Subjective - What You Are Told

Describe the patient, specifically age and gender.
Chief complaint.
What the patient tells you, including history of the present event and answers to your OPQRST questions. Guess what ... if the patient has a potty mouth and this disposition is important to the situation, go ahead and include the quotes, but don't forget quotation marks!
What other people at the scene tell you: other responders, witnesses, police.
Previous medical history.
Current medications, physician(s).
Allergies.

Objective - What You See/Hear/Feel

Initial impression of the patient, including his or her location and position.
Vital signs, including breath sounds.
Physical exam findings and level of consciousness. It can be separated into primary (ABCDs) and secondary (body systems head to toe, so it's easy to remember).
General observations and other noteworthy information such as environmental conditions, patient behavior, etc.
Description of the scene, such as amount of damage to the vehicle's windshield, steering wheel and passenger compartment.

Assessment - Your Diagnosis

Diagnostic conclusion(s) based on the patient's chief complaint and your physical exam findings.
You may have more than one problem listed and can qualify each with "possible" or "rule out."

Plan - What You Did

This is the only portion of your patient care report that should be chronological.
Describe what was done for the patient and how he or she responded to treatment. This should include what was done prior to your arrival, how care was discontinued or transferred, and the condition of the patient upon departure.

You may want to include information about who had control of the patient's personal belongings upon your departure or where they were left. For example, if you left her purse in the tray underneath the hospital bed, make a note of it so you aren't to blame if the purse disappears.

Always keep in mind the importance of this document:

It is a medical record that must be treated confidentially, as defined by HIPAA regulations.
It is a legal document you may have to defend in court much later, after your memory has faded.
It is an historical record of the event from which a bill of service will be generated.

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Updated 09.12.05

"Better keep yourself clean and bright; you are the window through which you must see the world."
—George Bernard Shaw