VII. PAS – Secondary Survey – SOAPnote:

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.

Subjective:
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.

Objective: 
The objective date consist of their vital signs, the patient exam, and the AMPLE history.

Vital signs: 
Time the vitals signs are taken:   
RR & Effort    
HR & Effort(BP)    
LOC    
Skin: C/T/M    

Patient exam:  Describe locations of pain, tenderness & injuries.
                                                                                                                                               
AMPLE history:
Allergies:           
Medications:             
Past pertinent medical history:         
Last intake & output:           
Events leading up to accident:         

A – Assessment:  (problem list)
1.                                                                                                                                                  
2.                                                                                                                                                   

P – Plan:  (plan for each problem on the problem list)
1.                                                                                                                                                   
2.                                                                                                                                                  
3.  MONITOR – reSOAP your patient every 5 – 15 minutes.

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