2007 SOAP Made Easy- cole.ppt
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This document provides guidance on effective medical documentation using the SOAP note format. It discusses the goals of documentation, including writing consistently, comprehensively, and in a legally defensible manner. It then covers the components of the SOAP note format, with subjective (S) covering patient-reported information, objective (O) focusing on clinical observations, assessment (A) stating the patient's conditions, and plan (P) outlining treatment. The document emphasizes writing objectively and avoiding judgment.
2007 SOAP Made Easy- cole.ppt
- 1. SOAP Made Easy Steve Cole Paramedic, CCEMT-P
- 2. Revision information Last modified 01-20-05 For more information on this or other presentations, contact: – Steve Cole – rcole@adaweb.net – colemedic@hotmail.com
- 3. Goals Write consistent and comprehensive documentation of patient care contacts. Write in a form acceptable through out the medical industry. Write charts in a legally defensible way. Write charts that demonstrate indications, responses, and other pertinent information behind interventions we do. Write charts that accurately tell the impact of EMS on any pt contact.
- 4. Basic concepts of documentation 1. BASIC "RULE" OF DOCUMENTATION: "IF YOU DIDN'T WRITE IT, IT DIDN'T GET DONE!" 2. THE PROFESSIONALISM OF THE REPORT REFLECTS ON THE PROFESIONALISM OF THE WRITER. 3. DOCUMENT THE SAME WAY EACH TIME .
- 5. "The best protection from liability is good pre-hospital care." "The best protection in a malpractice proceeding is good documentation."
- 6. Why Document? Professional responsibility Legal protection Regulatory standards Reimbursement
- 7. The PCR as a legal document “Business Record”. We are in the patient care business, it is a record of our business. – Discoverable in court. – Reflects directly on the credibility of the author. Refreshing of memory of testimony
- 8. Barriers to Good Documentation
- 9. Educational Emphasis Covered Briefly in initial training. – Only a few pages in most text books. Not tested, reviewed Inconsistent training methods Different Styles, all correct. – Its not a “Skill Station”
- 10. Blind leading the blind Usually taught “on the Job” Sometimes those who are teaching are teaching bad habits based on misconceptions, out dated information, or outright bad information. Only corrective action is often for billing purposes.
- 11. "Drudgery" vs. Personal Challenge Improving documentation skills and discovering enjoyment in charting requires personal effort, study, and practice. Self esteem and the desire to excel can motivate this personal effort, yielding great personal satisfaction, a sense of accomplishment, and professional respect.
- 12. Standards (lack there of) Abbreviations Permissible errors Addendums Format
- 14. Handwriting Handwritten Charts Concerns: – Legibility – Spelling errors – Reluctance to rewrite – Poor legibility = perceived attempt to cover up mistakes Solution: Computerized Charts – Legible – Easy and quick to correct – Professional appearance.
- 15. Open Spaces Parts of the run form not completed may be perceived as laziness in a court room. Time Entries not completed are most common. Fill in blanks on chart forms – “n/a”
- 16. Vital Signs Minimum of one complete set for every patient Two sets preferred. One early on, one prior to release.
- 17. Relevant vs. Judgmental ? Profanity. Criminal Behavior prior to call. Misc. Statements of bystanders. Prior EMS Contacts. Memory Recall
- 18. Dotting the I’s Document the clinically significant details Sign every entry Write neatly and legibly Use proper spelling, grammar, and appropriate medical phrases Document in blue or black ink and use military time
- 19. Crossing the T’s Use authorized abbreviations – Department approved abbreviations Record the patient’s name on every page Chart promptly Chart after delivery of care
- 20. Other Minutia: Document exact quotes Eliminate bias from written descriptions of patients Do not tamper with records Correctly identify late entries Record only accurate information (mg , etc)
- 21. Legal Do not omit significant information from the chart Correct mistaken entries properly – Initial, single line – 3 mistakes total per ACEMS standards for written documentation Do not rewrite the record Do not lose or destroy medical records (HIPAA) Do not add to the notes of others
- 22. LEGAL ALWAYS BE SURE YOUR RECORD DOES NOT CONTRADICT ITSELF!
- 23. The importance of Perception Often Legal action is taken because of Act of Omission, no Commission. We are (most often) sued because of something that was not done. – We didn’t treat a condition – We didn’t provide transport – We didn’t take time to… Many times this results in a underlying perception that we didn’t care enough to do our job.
- 24. The importance of Perception It is important that our patient chart clearly shows that we were not just bystanders to the patients condition, but we took an active part in being a pt advocate. This changes the perception from us being a lazy medic who didn’t take the time to transport (or treat) the patient to a caring individual who tried to take care of a patent but the patient (or situation) prevented it.
- 25. The importance of Perception Examples: – Refusals: » “Transport was clearly offered” » “Informed refusal of care obtained, risks explained including death, and pt declined” – Getting Family, case worker, etc. involved. – Advising the patient of alternative resources for getting assistance. – Calling ahead to hospital to advise them of patients ETA if arriving via POV.
- 27. Patient Confidentiality Most common wrongdoing of EMS “What happens on the job stays on the job!” -Be careful of what you say in restaurants, elevators, EMS room If you have a patient that comes to the station requesting a copy of PCR you must receive written request, follow departmental policies, etc.
- 28. Exceptions for release of data: “need to know”- other providers at risk Assault & battery, rape, abuse, etc. Third party billing for medicare/medicaid Proper subpoena Appropriateness of release of information Still need to follow policy.
- 29. Invasion of Privacy When you break confidentiality agreement releasing information without patient consent – Discussing someone's STD with others – Implying someone was DWI – Discussing Domestic battery cases
- 30. What is HIPAA Health Insurance Portability and Accountability Act – Est. in 1996 by The Centers for Medicaid and Medicare (CMS) This is the federal regulations that are now put in place to protect protected health information (PHI). Also sets forth standards for electronic health care transactions. – If you ask me this is like the standard patient confidentiality practices we’ve all been taught on crack!!??
- 31. What is PHI Protected Health Information – ANY information that can ID that pt to a medical problem. – SSN, DOB, Name – Address Incidental Disclosure – Bystanders – Public View – Radio
- 32. Goals of HIPAA Limit the non-consensual use and release of private health information Give patients new rights to access their medical records and to know who else has accessed them Restrict most disclosure of health information to the minimum needed for the intended purpose Establish new requirements for access to records by researchers and others
- 33. Goals of HIPAA Establish new criminal and civil sanctions for improper use or disclosure of PHI – Civil penalties for inappropriate disclosure are $100 per episode and no more than $25,000 per calendar year. – Inappropriate disclosure of PHI can be punished by $50,000 fine and up to one year in the pen. – Obtaining PHI under false pretenses can be punished by $100,000 fine and up to 5 years in the pen. – PHI disclosure for commercial use, personal gain, or malicious harm can lead to $250,000 fine and up to 10 years in the pen. (Sorry, you can’t say Bob Dole will die before his term is up again) » These fines and assessments have been published but there will be a whole separate rule published eventually that outlines and describes the infractions and fines further.
- 34. HIPAA Three Approved reasons for HIPAA Disclosure – Legally mandated reporting » Subpoena – Operational Uses » Educational Uses » QA/QI – Transfer of Care » FULL DISCLOSURE
- 35. HIPAA Compliance HIPAA Training Safeguards – Policy – Physical/Electronic Access controlled Notification of Privacy Procedures to pt’s or family. – Good Faith Paperwork – Signature forms ALL PATIENTS YOU COLLECT PHI ON!
- 37. Charting systems Effective and efficient charting has been an issue to medicine throughout history. Numerous methods of charting have evolved over time. More are evolving every day.
- 38. Narrative Method A diary or story like approach to the recording of patient care Are more efficient if used in combination with flow sheets for recording some repetitive data
- 39. Narrative Method Advantages: Good for triage systems, quick entries familiar to most nurses – can be easily combined with other methods » “P” in SOAP
- 40. Narrative Method Disadvantages: lack of structure task oriented and time consuming information may be difficult to retrieve does not always reflect critical thinking, decision making and analysis
- 41. CHART Method A Problem Oriented method of charting C: Chief Complaint H: History (AMPLE) A: Assessment R: Rx (Treatments done) T:Transport (Events during transport)
- 42. CHART Method Advantages: Good as a format for verbal reports, Simple to remember Disadvantages: Is not accepted outside of the EMS community Does not take into account other factors beside pt care (like scene survey, etc) Not as comprehensive as other forms.
- 43. Charting by exception Includes flowsheets, documentation by reference to standards of practice, protocols, a nursing data base, nursing diagnosis based care plans and SOAP progress notes
- 44. Charting by exception Basically the Idea of charting only exceptions to the norms If the lungs are clear and equal, then it doesn’t get charted. Requires a defined set of “norms” to function correctly Gained popularity but is now disappearing.
- 45. Charting by exception Advantages Quick and easy Very little time involved. Provider friendly. Disadvantages can require duplication of charting Does not accurately paint a picture. may impact reimbursement Poorly defensible
- 46. Computerized Charting One of the strongest trends in EMS documentation throughout the US and Canada. Very common in the larger Systems in this area.
- 47. Computerized charting Advantages – Legible records – Readily available records – (allegedly) Improved productivity – Reduction in record tampering – Better QA process – Better Data Collection – Reduction in redundant documentation – Clinical prompts, reminders, and warnings
- 48. Computerized charting Disadvantages – Unfamiliar to users – Lack of portability – Problems with security and confidentiality – Disruptive computer downtime – Size of the record – Erroneous acceptance of information – Limitation of format
- 49. Computerized charting Disadvantages, cont – Resistance – Cost – Legal Defensibility from poorly written narratives – THE PT DOES NOT FIT THE COMPUTER PROGRAM
- 50. SOAP charting A problem oriented charting method Subjective data Objective data Assessment Plan
- 51. SOAP Method Has been expanded in NURSING to include – SOAPIE » add Interventions » add Evaluation – SOAPIER » add Revision
- 52. SOAP Method Advantages: well structured reflects the care process easier to track particular problems for QI can be used effectively with standard care plans frequently used in the integrated plans Is used through out the medical and billing community.
- 53. SOAP Method Disadvantages: requires rethinking documentation process can be redundant not the Quickest has met some resistance due to effort needed to document correctly.
- 54. At Ada County EMS we have implanted a computer charting system , but we still write a SOAP note with in the system. This gives us good defensible charts while retaining data management and QA functions.
- 56. SUBJECTIVE EVERYTHING you find out about the pt from something other than direct observation/Assessment Information from the pt. Information from the PD Information from the Chart (Exception: some diagnostics) Information from other medical providers prior relating to care prior to your arrival
- 57. Dispatch Information Keep separate from main body of the SOAP, still important. Very important with multiple pt’s. “Medic 1 dispatched to MVC. On arrival presented with multiple patients, this is pt 2 of 4 seen by this unit.” Be sure you coordinate with other providers so your numbers match up. Good place to document delays, wrong directions, etc.
- 58. S: “once upon a time” Your opening lines can break a subjective – Pt. Age, C/C or reason why they were unable to present one. – Followed by Secondary Chief complaints. “Pt is a 31 y/o male with c/c of lower back pain secondary to fall. Pt also complains of SOB, Nausea, and dizziness”
- 59. S: Quotes Pt States: Exact verbage Pt reports: summery Guess what ... if the patient has a potty mouth and this disposition or information is important to the situation, go ahead and include the quotes, but don't forget quotation marks!
- 60. S: OPQRST Very Important when describing any type of Pain. Can be used very effectively for other types of discomfort (chest pressure, tightness, etc) and complaints (nausea, vertigo, etc)
- 61. S: “OPQRST” Pain Questions – Onset - when start, sudden or gradual. Activity at onset. – Provoke - position, movement, local or general – Quality - sharp, dull – Radiating - if so, from where to where – Severity - mild-moderate-severe or scale of 1-10 – Time - how long, continuous or intermittent, worse or better. Crescendo pattern.
- 62. S: Previous episodes Prior episodes, what brought it on? Seen By an doctor? Self or prescribed treatment (w/ or w/o success) Crescendo pattern?
- 63. S:Pertinent positives and negatives Depends on c/c Very important Can protect you or open you up Common ones : Chest discomfort, SOB,. N/V, Near syncopal episodes, dizziness, previous episodes.
- 64. OBJECTIVE Just the facts mam” Clinical, objective, non judgmental Think scientific Think MR. Spock as a paramedic.
- 65. O: VEHICLE DAMAGE/SCENE SURVEY General hygiene of area – Food in fridge, Garbage overflowing, fecal matter on floor or in bed. Vehicular damage (or lack there of) – Points of impact, distance from road, windshield starring, steering column damage, etc. Pill bottles, drug paraphernalia Crowd/safety issues.
- 66. O: The Pt Who is with the pt – PD, Nurse at bedside, family, bystander, little green men Position of the pt? – Recumbent, supine, simi-fowlers, standing Interventions in effect? – O2, IV ,C-collar, Manual C-Spine, – “Stare of life” What is the pt doing? – Walking, Running, Fighting, yelling, gurgling, tripoding
- 67. O: LOC LOC is the most important descriptor in the primary survey, as it will be examined closely in DWI cases, mental holds, criminal prosecution, REFUSALS, etc. Conscious , alert, oriented to person , place, time (x3) Cooperative Mental affect, demeanor Short vs long term memory Cognition
- 68. O: Primary Survey, rapid survey, etc… Examples LOC: Mentation, described before Airway: Clear, snoring Breathing: Labored, Non labored, retractions, grunting, speech dyspnea, audible wheezes Circulation: Skin pallor, distal pulses quality Disability: Mini nuero, left sided deficits, slurred speech, unstable gait, moves all ext well.
- 69. O: Head to toe HEENT: NECK/BACK: CHEST: ABD: PELVIS/LOWER EXT: UPPER EXT: NEURO: Detailed Neuro (optional)
- 70. O: Diagnostics Blood Glucose: State source (IV stick, capillary blood) Pulse OX: before and after O2 or BVM, neb, etc EKG/ 12 lead (if you are qualified to read, may be cosigned by medic ) Temp: Oral, axillary, rectal, etc ETCO2.
- 71. O: Vital Signs Vital signs may be recorded in “O”, “P”. Or elsewhere in chart depending on PCR layout. Vital Signs Record: 2 Sets Minimum; "serial" VS; Palpated vs. auscultated B/P VS: palpated B/P documentation; respiratory rates (and techniques for correctly counting them). Documentation of Orthostatic ("Postural") VS changes: using stick figures to indicate the patient's position during VS measurement.
- 72. Assessment Field Diagnosis No “red swollen deformed extremities” – Call a Fx a Fx! R/O, Rule Out: Cop Out Possible, probable etc are looked down on for billing purposes, but may be used if you don’t bill. – OK as a supplement to a DX “Altered Mental staus , probable herion overdose” Chronic problem that got worse? : “exacerbation of” VS. Try to have at least two diagnosis
- 73. Assessment continued Syndromes are a collection of predictable symptoms from a common cause; – Hyperventilation syndrome Diagnosis of exclusion – Dx made only after all other things have been ruled out. Common pitfall, be very careful – Alcohol intoxication, – Anxiety, Psuedo-Seizure – Muscular neck pain
- 74. A: Common assessments Soft tissue injury secondary to fall Pleuratic pattern Chest wall pain Ischemic pattern Chest pain Syncope/near syncope of unclear origin TIA , CVA with left sided deficits Multi system trauma Hypoglycemia (may add resolved) Post Seizure, Active Seizure , Status epilepticus Altered Mental Status- Probable Heroin Overdose
- 75. The PLAN Chronological detail of pt contact beginning with on scene. Use time notations. – Exception: may place pert . Info to call that occurred and caused a delay to pt contact, like dispatch error, ect. – “(2030) On scene, contact delayed secondary to scene sfety issues. EMS staged. – “(2040) Pt contact and assessment” Use 3rd person. Both Subjective and Objective. Itemize
- 76. P: Interventions Time? What? Who? How Much? Response/adverse effects? OBJECTIVE and SUBJECTIVE. Why? “(2031) Oxygen applied by S. Cole for SOB at 10 LPM NRB mask with pt reporting some relief. Pt work of breathing decreases.Chest pain decreases to 4/10.”
- 77. P: Reassessments Document reassessments to justify doing or with holding interventions. “(2035) Reassessment finds increased work of breathing, decreased tidal volume, and pt unresponsive. Sats decreased to 66%” “(2035) NRB mask changed to PPV via BVM with 30 fr. OPA by S. Cole with Sats increasing to 90%.”
- 78. P: Critical Events Critical events that do not fall into other categories are still documented chronologically. (2038) RN on location presents EMS with a valid Comfort One DNR (#xxx). (2038) Pt’s Mother on scene, becoming violent , restrained by PD, requiring EMS to relocate pt to MICU”
- 79. P: refusals “Risks explained” “transport options discussed” “Pt deciles transport” “Informed refusal of services”
- 80. P: End of call Transfer of care: “Report to XXX” “Pt left on scene with PD. Belongings: “all paperwork, purse (with undisclosed contents) and other belongings at bedside (to EMS staff, etc.).” Pt condition on d/c: “Pt alert , oriented, calm, and in no apparent distress” “Pt tearful, tachypniec, and yelling at EMS on clearing”. HIPAA and/or billing completed?
- 81. P: After notes Itemizing of : – Drugs – ET attempts – Shocks – Etc Other facts.
- 82. Special Situations: Crime Scenes You are writing a MEDICAL report, not a criminal investigative report. Don’t neglect good documentation of pt medical condition for documentation of criminal events. That said, don’t neglect events pertinent to pt’s medical condition if they involve criminal activity.
- 83. Final thoughts Use protocols, articles, medical text books to be sure you cover all points in a medical complaint Use medical dictionaries frequently Document in third person. Use a set format, each and every time that covers all facets of pt care.