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SOAP notes • • • • • • • Subjective: (age, sex, mechanism of injury (MOI), chief complaint (c/c) & description of pain P.Q.R.S.T.) _________________________________________________________________ Objective: vital signs (VS), patient exam (PE), AMPLE history Time ____ ____ ____ ____ Level O Cons. ____ ____ ____ ____ Vital Respir. Rate ____ ____ ____ ____ Heart Rate ____ ____ ____ ____ • Blood Press. ____ ____ ____ ____ • Skin (C.S.M.) ____ ____ ____ ____ • Pupils ____ ____ ____ ____ • Temp ____ ____ ____ ____ • • • • • • • • • • • • • • • • • • • • Signs Patient exam: Describe location of pain and injuries _________________________________________________________________ _________________________________________________________________ AMPLE: Allergies _________________________________________ Medications _________________________________________ Previous injury or illness__________________________________ Last Meal _________________________________________ Events leading up to the accident___________________________ Assessment: (problem list) 1.________________________________________________________________ 2.________________________________________________________________ 3.________________________________________________________________ 4.________________________________________________________________ Plan: (plan for each problem on the problem list - bivouac, transportation, etc.) 1.________________________________________________________________ 2.________________________________________________________________ 3.________________________________________________________________ 4.________________________________________________________________ 5.MONITOR - How often do you plan to monitor the patient_________________ Provokes Quality Radiates Severity Time Alert Verbal Pain Unresponsive Color Sensation Moisture