EMS SOAP

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posted 2020-04-16, updated 2021-06-17
Assessment & Plan Elements, Emergency Medical Services
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DISPATCHED TO:[textarea name="dispatch" default=" "]

RESPONSE: [checkbox name="RESPONSE" value="EMERGENT.|NONEMERGENT.|LIGHTS/SIRENS.|LIGHTS NO SIRENS.|NO LIGHTS NO SIRENS.|UPGRADED TO EMERGENT.|DOWNGRADED TO NONEMERGENT."][text name="RESPONSE" default=" "]

DISPATCH PRIORITY: [checkbox name="priority" value="Alpha.|Bravo.|Charlie.|Delta.|Echo.|Transfer."][text name="priority" default=" "]
**************************************************
COVID-19 QUESTIONS:
 
Close contact with person with confirmed or suspected COVID-19: [select name="variable_2" value="NO|YES"]

Travel to high risk COVID-19 areas per current local guidance: [select name="variable_3" value="NO|YES"]

SYMPTOMS:

[checklist name="variable_1" value="+Shortness of breath|-Shortness of breath|+Cough|-Cough|+Fever|-Fever|+Sore throat|-Sore throat|+Loss of smell|-Loss of smell|+Nausea|-Nausea|+Vomiting|-Vomiting|+Flu like Sx|-Flu like Sx"]

Onset:[text name="Onset"]

Quarantine: [checkbox name="Quarantineintiated" value="Yes |No"] Isolation: [checkbox name="Isolationintiated" value="Yes |No"]

Symptoms are [select name="variable_4" value="IMPROVING|WORSENING|STAYING THE SAME"] since onset.
***********************************************

ATF [text name="variable_1" default="sample text"]year old  
[select name="variable_1" value="Male|Female|"]

Pt complaint of [text name="CC" size = 55 default=" "] with a secondary complaint of [text name="CC" size = 55 default=" "].
Pt stated [textarea name="HX_OF_PRESENT_ILLNESS" default=" "].
Pt stated history of [textarea name="variable_1" default=" "].
Primary Assessment.

AIRWAY:
[checkbox name="airway" value="airway open.|airway patent.|no airway obstuctions.|airway positioned to open.|airway not patent.|obstructions to airway.|requires airway adjunct.|requires advanced airway.|requires artificial ventilation."][text name="airway" default=" "]
BREATHING:
[checkbox name="breathing" value="breathing spontaneously.|breathing regular.|adequate respirations.|appropriate tidal volume.|no apparent life threats to breathing.|not breathing spontaneously.|irregular respirations.|inadequate respirations.|inadequate tidal volume.|apparent life threats to breathing."][text name="breathing" default=" "]
CIRCULATION:
[checkbox name="circulation" value="no obvious bleeding.|pulses intact.|skin color appropriate.|cap refill <2seconds.|no life threats to circulation status.|hemorrhage present.|hemorrhage controlled.|tourniquet applied.|pulses not intact.|skin color not appropriate.|cap refill >2 seconds.|life threatening concerns with circulation."][text name="ros_constitutional" default=" "]
**********
[checkbox name="ros_constitutional_check" value="no fever.|no chills.|no weakness.|no fatigue.|fever.|chills.|weakness."][text name="ros_constitutional" default=" "]
[checkbox name="ros_heent_check" value="no vision changes.|No ear pain.|no nasal congestion.|no sore throat.|no cough."][text name="ros_heent" default=" "]
[checkbox name="ros_cardio_check" value="No chest pain|no palpitations.|no swelling of extremities.|chest pain.|palpitations.|swelling of extremities."][text name="ros_cardio" default=" "]
[checkbox name="ros_resp_check" value="No shortness of breath.|no hemoptysis.|no dyspnea.|shortness of breath.|hemoptysis.|dyspnea."][text name="ros_resp" default=" "]
[checkbox name="ros_gi_check" value="No change in appetite.|no abdominal pain.|no hematemesis.|change in appetite.|no N/V/D.|Abdominal pain.|hematemesis.|Nausea.|Vomiting.|Diarrhea."][text name="ros_gi" default=" "]
[checkbox name="ros_gu_check" value="no urinary frequency.|no urinary urgency.|no dysuria.|no hematuria.|no leakage of urine.|urinary frequency.|urinary urgency.|dysuria.|hematuria.|leakage of urine."][text name="ros_gu" default=" "]
[checkbox name="ros_msk_check" value="no back pain.|no joint pain.|no muscle aches.|no generalized muscle pain.|no neck pain.|back pain.|joint pain.|muscle aches.|generalized mucle pain.|neck pain."][text name="ros_msk" default=" "]-Skin: [checkbox name="ros_skin_check" value="no rash.|no bruising.|no lesions.|no itching.|rash.|bruising.|lesions.|itching."][text name="ros_skin" default=" "]
[checkbox name="ros_neuro_check" value="no headache.|no dizziness.|no syncope.|no loss of consciousness.|headache.|dizziness.|syncope.|loss of consciousness."][text name="ros_neuro" default=" "]
[checkbox name="ros_psych_check" value="denies Suicide ideation/homicide ideation.|No hallucination.|No depression.|no anxiety.|Suicide ideation\homicide ideation.|hallucinations.|depressed.|anxious."][text name="ros_psych" default=" "]
[checkbox name="ros_endo_check" value="no heat/cold intolerance.|no excessive thirst.|no polyuria.|heat intolerance.|cold intolerance.|excessive thirst.|polyuria"][text name="ros_endo" default=" "]
[checkbox name="ros_heme_check" value="no excessive bruising.|no excessive bleeding.|excessive bruising.|excessive bleeding."]

Vitals were as follows: BP;[text name="pe_bp" default=" "] P;[text name="pe_pulse" default=" "] R;[text name="variable_1" default="     "]SPO2;[text name="pe_spo2" default=" "]
BGL;[text name="pe_bgl" default=" "]

HEENT assessment found [checkbox name="pe_heent_check" value="normocephalic.|atraumatic.|PERRLA.|white sclera.|conjuntiva pink/red|ears patent.|no bleeding.|bleeding.|positive HALO test.|negative HALO test.|dry mucous membranes.|extra salivation. |normal mucous.|normal pharynx.|no trauma to mouth.|trauma to face.|trauma to mouth."][text name="pe_heent" default=" "]
Psych assessment found [checkbox name="pe_cardio_check" value="Regular rate and rhythm.|no ST elevation.|no jugular vein distention.|no edema.|peripheral pulses intact.|no cyanosis.|capillary refill < 2 seconds.|irregular rate.|irregular rhythm.|ST elevation present.|JVD present.|edema present.|no peripheral pulses.|cyanosis present.|capillary refill greater than 2 seconds.|bleeding.|trauma.|atraumatic."][text name="pe_cardio" default=" "] Respiratory assessment found [checkbox name="pe_resp_check" value="Clear to Auscultation bilaterally.|no rales, rhonchi, wheezes.|no retractions.|no accessory muscles being used.|no stridor.|wheezing.|upper respiratory congestion."][text name="pe_resp" default=" "] GI assessment found[checkbox name="pe_gi_check" value="atrumatic.|BS present in all 4 quadrants.|abdomen soft/nontender to palpation.|nondistended.|No rigidity.|no guarding.|no masses."][text name="pe_gi" default=" "] MSK assessment found [checkbox name="pe_msk_check" value="normal Range of movement.|no pain on palpation.|strength 5/5 in all extremities.|abnormal range of motion.|pain on palpation.|strength not present in all extremities.|"][text name="pe_msk" default=" "] Skin [checkbox name="pe_skin_check" value="no rash.|no lesion.|no discoloration.|pink.|warm.|dry.|pale.|cool.|cyanotic.|flushed.|clammy.|hot."][text name="pe_skin" default=" "] Neurological assessment found [checkbox name="pe_neuro_check" value="Grossly oriented X 4.|gait normal.|sensation intact.|normal reflexes.|smile normal.|speech not slured.|Neuro not grossly intact.|gait abnormal.|sensation absent.|no reflexes.|smile not symmetrical.|slurred speech."][text name="pe_neuro" default=" "]
[checkbox name="pe_psych_check" value="Pleasant, calm and cooperative.|Judgement and insight intact.|makes a plan.|understands treatment.|thought process normal.|normal affect.|unpleasant.|not calm.| not cooperative.|does not make plan.|does not understand treatment."][text name="pe_psych" default=" "]

Primary Impression: [text name="PI" size = 55 default=" "]

Secondary Impression: [text name="SI" size = 55 default=" "]

TREATMENT:[textarea name="Treatment" default=" "]

Report given to [checkbox name="pe_rep_check" value="Verbal report to nurse.|belongings left with nurse.|improvement in patient condition.|decline in patient condition.|no change in patient condition."][text name="pe_rep" default=" "]
DISPATCHED TO:


RESPONSE:

DISPATCH PRIORITY:
**************************************************
COVID-19 QUESTIONS:

Close contact with person with confirmed or suspected COVID-19:

Travel to high risk COVID-19 areas per current local guidance:

SYMPTOMS:



Onset:

Quarantine: Isolation:

Symptoms are since onset.
***********************************************

ATF year old


Pt complaint of with a secondary complaint of .
Pt stated
.
Pt stated history of
.
Primary Assessment.

AIRWAY:

BREATHING:

CIRCULATION:

**********






-Skin:





Vitals were as follows: BP; P; R;SPO2;
BGL;

HEENT assessment found
Psych assessment found Respiratory assessment found GI assessment found MSK assessment found Skin Neurological assessment found


Primary Impression:

Secondary Impression:

TREATMENT:


Report given to

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.45, 73 form elements, 93 boilerplate words, 36 text boxes, 4 text areas, 28 checkboxes, 1 check lists, 4 drop downs, 293 total clicks
Questions/General site feedback · Help Ticket

5 responses to “EMS SOAP”

  1. scoobie69d says:

    I’m having trouble with this (really all of my soap notes) When I fill them out and Calculate results then copy to clipboard, they don’t copy correctly. I get wrong data, repetitive data and some spots just don’t copy.

    Reply
    • SOAPnote says:

      Hello – could you point me to a specific part that’s not coming out right? I’ll take a look at it.

      Reply
      • scoobie69d says:

        DISPATCHED TO:123 Main St

        RESPONSE: EMERGENT.

        DISPATCH PRIORITY: Alpha.
        **************************************************
        COVID-19 QUESTIONS:

        Close contact with person with confirmed or suspected COVID-19: NO

        Travel to high risk COVID-19 areas per current local guidance: NO

        SYMPTOMS:

        [+] +Shortness of breath
        [-] -Shortness of breath
        [+] +Cough
        [-] -Cough
        [+] +Fever
        [-] -Fever
        [+] +Sore throat
        [-] -Sore throat
        [+] +Loss of smell
        [-] -Loss of smell
        [+] +Nausea
        [-] -Nausea
        [+] +Vomiting
        [-] -Vomiting
        [+] +Flu like Sx
        [-] -Flu like Sx

        Onset:

        Quarantine: No Isolation: No

        Symptoms are IMPROVING since onset.
        ***********************************************

        ATF sample textyear old
        Male

        Pt complaint of breathing with a secondary complaint of breathing.
        Pt stated breathing from nose.
        Pt stated history of not breathing from nose.
        Primary Assessment.

        AIRWAY:
        airway open., airway patent., no airway obstuctions., airway positioned to open.
        BREATHING:
        breathing spontaneously., apparent life threats to breathing.
        CIRCULATION:
        no obvious bleeding.
        **********
        no fever., no chills., no weakness.
        no vision changes.
        No chest pain

        -Skin: no rash., no bruising., no lesions., no itching.

        denies Suicide ideation/homicide ideation., No hallucination., No depression., no anxiety.

        Vitals were as follows: BP; 120/80 P;80 R;sample textSPO2;98
        BGL;122

        HEENT assessment found normocephalic., atraumatic., PERRLA., white sclera., conjuntiva pink/red
        Psych assessment found Regular rate and rhythm., no ST elevation., no jugular vein distention., no edema., peripheral pulses intact. Respiratory assessment found Clear to Auscultation bilaterally., no rales, rhonchi, wheezes., no retractions., no accessory muscles being used. GI assessment found MSK assessment found Skin no rash., no lesion., no discoloration., pink., warm. Neurological assessment found Grossly oriented X 4., gait normal., sensation intact., normal reflexes.
        Pleasant, calm and cooperative., Judgement and insight intact., makes a plan.

        Primary Impression: see below

        Secondary Impression: see above

        TREATMENT: quoted

        Report given to Verbal report to nurse.

        Reply
        • SOAPnote says:

          What if you used

          [checklist name="variable_1" value="Shortness of breath|Cough|Fever|Sore throat|Loss of smell|Nausea|Vomiting|Flu like Sx"]

          instead of

          [checklist name="variable_1" value="+Shortness of breath|-Shortness of breath|+Cough|-Cough|+Fever|-Fever|+Sore throat|-Sore throat|+Loss of smell|-Loss of smell|+Nausea|-Nausea|+Vomiting|-Vomiting|+Flu like Sx|-Flu like Sx"]

          Then it would show [-] in front of the negative ones and [+] in front of the positive ones.

          If you want there to be other options such as ‘not asked’ or ‘not applicable,’ you’d need to have an individual form item for each symptom.

          That would look like
          [select name="variable_10" value="(-)|(+)|not asked|not applicable"] Shortness of breath
          [select name="variable_11" value="(-)|(+)|not asked|not applicable"] Cough
          [select name="variable_12" value="(-)|(+)|not asked|not applicable"] Fever
          [select name="variable_13" value="(-)|(+)|not asked|not applicable"] Sore throat
          [select name="variable_14" value="(-)|(+)|not asked|not applicable"] Loss of smell
          [select name="variable_15" value="(-)|(+)|not asked|not applicable"] Nausea
          [select name="variable_16" value="(-)|(+)|not asked|not applicable"] Vomiting
          [select name="variable_17" value="(-)|(+)|not asked|not applicable"] Flu like Sx

          It wouldn’t put [ and ] around the – or + for the items if you did it that way, but it would be close with ( and ) around the + and -.

          Reply

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