Part 7 of 9: PAS – SOAP note: What is our patient care plan?
The SOAP note is organized into the Subjective date, Objective date, the Assessment, and the Plan.
The subjective date is their age, sex, the mechanism of injury (MOI), and the chief complaint (C/C), i.e., what they are complaining of.
The objective date consist of their vital signs, the patient exam, and the AMPLE history.
Time the vitals signs are taken:
RR & Effort
HR & Effort(BP)
Patient exam: Describe locations of pain, tenderness & injuries.
Past pertinent medical history:
Last intake & output:
Events leading up to accident:
A – Assessment: (problem list)
P – Plan: (plan for each problem on the problem list)
3. MONITOR – reSOAP your patient every 5 – 15 minutes.
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