SOAP 2022

Incident/Dispatch:[textarea name="incident" default=" "]

-----SUBJECTIVE-----
Upon Arrival: [textarea name="UA" default=" "]
History of Present Issue: [textarea name="HPI" default=" "]
Hx: PMH, Rx, Allergies Noted- [textarea name="e" size = 55 default=" "]
Other Hx Info: [textarea name="otherhx" default=" "]

Reveiw of Systems:
HEENT: [textarea name="HEENT" default=" No change in vision. No changes in hearing. No symptoms of upper respiratory tract infection.  "]
CNS: [textarea name="CNS" default=" Speech is not slurred. CMS grossly intact in all 4 extremities. Gait is steady. "]
PSYCH: [textarea name="psych" default=" No reported recent or active suicidality or homicidal ideations. No reported recent or active visual/auditory disturbances. "]
CARDIOVASCULAR: [textarea name="cardiovascular" default=" No reported palpitations. No reported chest pain or discomfort.  "]
PULMONARY: [textarea name="PULM" default=" No reported SOB. No reported cough. "]
GI/GU: [textarea name="GIGU" default=" No reported nausea and vomiting. No changes in bowel reported. No changes in urine reported. "]
MUSCULOSKELETAL: [textarea name="msk" default=" No reported musculoskeletal pain or injuries. "]

-----OBJECTIVE-----
Physical Exam:
GENERAL: [textarea name="general" default=" Interacting with EMS appropriately; well appearing; not acutely distressed. Mucous membranes are moist. "]
HEAD: [textarea name="head" default=" No noted trauma. Pupils equally round/reactive at 4mm in size. No facial droop. "]
NECK: [textarea name="NECK" default=" No noted trauma. No JVD. No midline pain. "]
CHEST: [textarea name="chest" default=" No noted trauma. Equal rise and fall. Normal and adequate tidal volume and respiratory drive. Breath sounds CTA bilaterally. "]
BACK: [textarea name="back" default=" No noted trauma. "]
ABDOMEN: [textarea name="abd" default=" No noted trauma. Soft, flat, non-tender on palpation. "]
PELVIS: [textarea name="pelvis" default=" No noted trauma. Stable. "]
EXTREMITIES: [textarea name="extremities" default=" No noted trauma. No clubbing, cyanosis, or edema. "]
SKIN: [textarea name="skin" default=" Normal tone, warm, dry. "]
VITALS: [textarea name="vitals" default=" "]
EKG: [textarea name="ekg" default=" "]
Additional Findings: [textarea name="additional" default=" "]



-----ASSESSMENT----
Impression(s): [textarea name="impression" default=" "]
Other Considerations: [textarea name="DDx" default=" "]

-----PLAN-----
Course of Treatment: 
[textarea name="treatment" default=" "]

Transport: 
[textarea name="TPU" default=" Transport non-emergent to HOSPITAL with pre-arrival notification made enroute. During transport patient remains stable."]

Hospital Arrival:
[textarea name="hosp" default=" Upon arrival at ED handoff given to nurse and provider at bedside. Nurse signs PCR. Patient signs PCR. "]

No further care.
-

[checkbox name="Student" value="*Some assessments and procedures were performed by paramedic student who was under my direct supervision as the attending paramedic, and consistent with student's scope of practice.*"]
[checkbox name="Disclaimer" value="*Please note that this dictation was completed with computer voice recognition software. Oftentimes unanticipated grammatical, syntax, homophones, and other interpretive errors are inadvertently transcribed by the computer software. Please disregard these errors. Please excuse any errors that have escaped final proofreading.*"]
Incident/Dispatch:

-----SUBJECTIVE-----
Upon Arrival:
History of Present Issue:
Hx: PMH, Rx, Allergies Noted-
Other Hx Info:

Reveiw of Systems:
HEENT:
CNS:
PSYCH:
CARDIOVASCULAR:
PULMONARY:
GI/GU:
MUSCULOSKELETAL:

-----OBJECTIVE-----
Physical Exam:
GENERAL:
HEAD:
NECK:
CHEST:
BACK:
ABDOMEN:
PELVIS:
EXTREMITIES:
SKIN:
VITALS:
EKG:
Additional Findings:



-----ASSESSMENT----
Impression(s):
Other Considerations:

-----PLAN-----
Course of Treatment:


Transport:


Hospital Arrival:


No further care.
-


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.06, 31 form elements, 60 boilerplate words, 29 text areas, 2 checkboxes, 31 total clicks
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