Wilderness Medicine Emergency SOAP Note Scene: Safe? How many? How bad ? MoI for spine? EVAC Numbers: 628.521-1510, RedPoint Emergency - AAC Method of Injury: Secure head/neck Look/Ask/Feel Patient ABCDE Stop + Fix SUB Name:
Age:
Sex: M/F Chief Complaint:
Airway: Breathing: Disability/decision (If no MoI):
_________Circulation/Blood Sweep:__________________ Env/ Exposure:_
________ ____,
Tattoo /Med-A-Lert: ______________________ Head-to-Toe Exam revealed: OBJ Vitals
Time Alert (Person/Place/Time/Event) Level of R +O__ ___+O__ HR x4= x4= RR x2= x2= kin olor emp oisture S C T M
/Verbal/Pain/Unresponsive ___+O__ ___+O__ x4= x4= x2= x2=
Reg/Irr : Strong/Weak Labored/Unlabored: Shallow/Deep
Include signs in the objective information. Make sure to also include symptoms in your notes as well. SX: Allergy: What: Exposure? Y/N/Unk Reaction: Tx: Medications: Name: For: Last Time Taken: Name: For: Last Time Taken: Name: For: Last Time Taken: Include dosage questions in the medications section: what, when, why, how much, did you have it today Hx: has this happened before, do you see a doctor on a regular basis for anything Food/ H2O: Last In/Out: What: PG? Y/N/Unk Blood Type, and Rh factor, if known: _____ Events: Recent Illness/Injury: events of the last 48 to 72 hours
Output Color/Consistency:
Focused Spine Assess: A+ O 3 /4 N/Y→ Sober? N/Y→ Free from distraction (pain): N/Y→ CirculationSensationMovement: N/Y (in all 4 extremities)→ Free of Spine Pain on palpation? Y/N (if yes to all then OK to move or release head) ASSESS: Based on MoI, Possible Possible PLAN, TX:
EVAC PLAN: ANTICIPATED PROBLEMS
Possible Possible