Complete Note
Share
Tweet
Cite
Incident/Dispatch:[textarea name="incident" default=" "]

Complaints: [textarea name="Chiefcomplaint" default=" "]

Hx:
Onset: [text name="O" size = 55 default=" "]
General Presentation:[textarea name="variable_1" default=" "]
Additional Signs/Symptoms Reported: [textarea name="s" size = 55 default=" "]
Allergies: [text name="a" size = 55 default=" "]
Medications: [text name="m" size = 55 default=" "]
Past Med Hx: [text name="p" size = 55 default=" "]
Events Surrounding Condition: [textarea name="e" size = 55 default=" "]

Assessment:
Airway: [checkbox name="airway" value="open. |maintained by patient.|no concerns for compromise.|not open.|compromised. |requires manual opening.|requires airway adjunct. |requires advanced airway."][text name="airway" size = 55 default=" "]
Breathing: [checkbox name="breathing" value="Adequate tidal volume and rate. |fast. |deep. |slow. |shallow. |apneic. "][text name="airway" size = 55 default=" "]
Circulation: [checkbox name="circulation" value="normal and without concerns. |Regular and normal pulse rate. |Tachycardic. |Bradycardic. |Weak pulse. |massive hemorrhage. |Diminished perfusion. | Pulseless. "][text name="airway" size = 55 default=" "]
Level of Consciousness: [checkbox name="loc" value="alert.|oriented.|Person.|Place.|Time. |Event.|disoriented. |arousable by verbal stimuli.|arousable by painful stimuli.|unresponsive."][text name="consciousness" size = 55 default=" "]
SKIN: [checkbox name="skin" value="pink.|warm.|dry.|pale.|cool.|clammy.|diaphoretic.|hot.|flushed.|cyanotic.|lividity.|jaundiced."][text name="skin" size = 55 default=" "]
HEENT: [checkbox name="head" value="no pertinent findings. |no reported pain. |pupils equally round and reactive."][text name="head" size = 55 default=" "]
Neck: [checkbox name="neck" value="no pertinent findings.|no JVD.|No tracheal deviation. |no reported pain."][text name="neck" size = 55 default=" "]
Chest: [checkbox name="chest" value="no pertinent findings.|breath sounds clear equal bilaterally. |equal chest rise |no reported pain."][text name="chest" size = 55 default=" "]
Back: [checkbox name="back" value="no pertinent findings. |no reported pain."][text name="back" size = 55 default=" "]
Abdomen: [checkbox name="abdomen" value="no pertinent findings.|no reported pain.| soft non tender on palp all quadrants"][text name="abdomen" size = 55 default=" "]
Pelvis: [checkbox name="pelvis" value="no pertinent findings. |no reported pain."][text name="pelvis" size = 55 default=" ]
Extremities: [checkbox name="extremities" value="no pertinent findings.|equal grip strength x4.|cap refill less than 2 seconds.|skin pink warm dry. |no reported pain."][text name="extremities" size = 55 default=" "]
GI/GU:[checkbox name="variable_1" value="No pertinent findings.|Dysuria.|polyuria.|diarrhea.|bloody stools"][text name=“extremities” size = 55 default=]
Psych:[checkbox name="variable_2" value="No pertinent findings.|Calm.|cooperative.|no SI/HI|suicidial ideation.|homicidal ideation.|ETOH use.|Drug use"][text name=“extremities” size = 55 default=]

Additional Assessment Findings: [textarea name="additassess" default=" "]
EKG: [checkbox name="ekg" value="12 lead EKG.|4 lead cardiac monitoring.|normal sinus rhythm.|sinus tachycardia.|no ST Elevation or ectopy.|no EKG performed."][text name="ekg" size = 55 default=" "]
Vital Signs: [textarea name="vitals" default=" "]
Impression: [text name="imp" size = 55 default=" "]

Rx:
Treatment included: [checkbox name="treatment" value="BLS assessment.|ALS assessment.|cardiac monitoring enroute.|IV access established "] [textarea name="rxt" default=" "]



TRANSPORT: [checkbox name="pe_trans_check" value="Secured to stretcher.|secured in airway seat.| Emergency.|Non Emergency.|Emergency Downgraded to Non Emergency. |Non Emergency Upgraded to Emergency.
|refusal.|treat and release.|no transport. |transported to St Lukes.|transported to Mercy.|transported to UIHC.|report called to receiving facility"][textarea name="pe_trans" default=" "]

Changes During Transport: [textarea name="changes" default=" "]

NPP/Signatures:[checkbox name="Variable_3" value="NPP offered.|NPP not offered due to pt status.|Signature obtained from PT.|signature obtained from RN."][text name="variable_1" default=" "]


Provider: [text name="prov" size = 45 default=" "]
Incident/Dispatch:

Complaints:

Hx:
Onset:
General Presentation:
Additional Signs/Symptoms Reported:
Allergies:
Medications:
Past Med Hx:
Events Surrounding Condition:

Assessment:
Airway:
Breathing:
Circulation:
Level of Consciousness:
SKIN:
HEENT:
Neck:
Chest:
Back:
Abdomen:
Pelvis:
Extremities:
GI/GU:
Psych:

Additional Assessment Findings:
EKG:
Vital Signs:
Impression:

Rx:
Treatment included:



TRANSPORT:

Changes During Transport:

NPP/Signatures:


Provider:

Result - Copy and paste this output:

Send Feedback for this SOAPnote

Your email address will not be published.

More SOAPnotes by this Author: