Phone: Notify



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SOAP Note




Date: Time:

Patient

Name: Age:

Address: M or F



Phone: Notify:
Relation: Phone:

Subjective

(moi c/c opqrst)

Objective

(Patient Exam SAMPLE History)

Vital Signs

Time

AVPU

HR/Character

RR/Character

SCTM














































Assessment




Plan











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Patient Assessment


Patient Name:

Date:

Time:

Airway







Breathing







Circulation







Disability







Environment







Focused Exam







Head/Neck Shoulders/Clavicle Chest/Sternum Abdomen Pelvis/Hips Legs/Feet Arms/Hands

Back Cervical Thoracic Lumbar Sacrum Coccyx


Get Vitals Time

Level of Responsiveness (AVPU) Heart Rate/Rhythm/Quality Respiration Rate/Rhythm/Quality Skin Color/Temp/Moisture



History
Chief Complaint
MOI (Mechanism of Injury)
Symptoms Onset

Provoke/Palliate Quality

Radiate (Leads to where?)
Severity (1-10)
Trend (When did it start)

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Allergies Medications Pertinent History Last Intake/Output Events Preceding



Rescue Request

Location


Quadrangle/Coordinates Area Description

On The Scene Plans

Stay Put Evacuate to trail to road to local shelter Will send some members out

Notes:


Equipment Needed

Food Water Shelter Stove and Fuel Sleeping Bags Climbing Hardware Rope Notes:

Weather


Temp: Hot Warm Cold Freezing
Precip: Dry Intermittent Rain Rain Snow Notes:

Type of Evacuation

Lowering Operating Carry Out Rigid Stretcher Helicopter None until specialized medical assistance Notes:

Remaining Party Members



Name Notify Phone

Notes









Vital Sign Record

Time

Heart Rate

Respiratory Rate

Skin

LOR

BP

Date Hour

Beats Per Minute

Character: Strong Weak Regular Irregular



Breaths Per Minute

Character: Deep Shallow Noisy Labored


Color Temperature Moisture


AVPU


Blood Pressure

















































































































































































































































































































































Focused Spine Exam: Date Time Patient Assessment/History Complete Reliable (A+0x3, Sober, No Distract Injury) CSM (4 Extremities) No Spine Tenderness





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DBB 11/01/07


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