Charting/ Documentation

what does SOAP stand for?

subjective (PMHx)

objective (VS)

assessment

plan

what is S in SOAP?

subjective

• pt’s complaints

• date started, what relieved the complaint, previous medical treatment, family hx

• PMHx reported by pt

what is O in SOAP?

objective

• VS, physical examination findings

• results of diagnostic/laboratory testing

what is A in SOAP?

assessment

• physician’s analysis of problem based on pt’s complaints & physical examination

• RT things, RT based issues

  • BS

  • look of chest

  • WOB

  • bloody secretions that need monitoring

what is P in SOAP?

plan

• tx plan including follow up

• surgery, scan, monitor & access ETT and pt progress

what does SBAR stand for?

situation

background (VS, PMHx)

assessment

recommendation

what is the S in SBAR?

situation

• age and gender

• what is going on w/ pt

• concise statement of problem

• time pt arrives, situation at hand

• are they on ETT & intubated?

what is the B in SBAR?

background

• pack years

• VS

• GCS

• clinical background info pertaining to situation

• PMHx

what is the A in SBAR?

Assessment

• what did you find? analysis & considerations of options

• RT based assessments like

  • barrel chest

  • accessory muscle use and BS (breath sounds)

  • WOB level also would go here. 

  • blood in mouth

what is R in SBAR?

recommendation

• what action/recommendation is needed to correct the problem? what do you want?

• CPAP, FIO2, adjusting it, diuretics lab test, admission

• monitoring ETT, monitor bloody secretions

• take to surgery, ICU

example 1 SBAR: 

67-year-old male, 50-pack year smoker arrives in the Emergency Department at 7:15 PM after a day watching football games on TV. Over 6 hours, he drank 3 beer, consumed a bacon cheese burger, potato salad, and popcorn. He is A & O x 4, RR 32, P 118, SpO2 90% on room air, 37.0 C temperature, systolic blood pressure 155 mmHg and diastolic blood pressure 110 mmHg. 

On visual inspection, barrel chest, clubbing, jugular venous distention, accessory muscle use in neck, chest, and belly are noted. On auscultation, bilobar crackles and wheezing.

Patient said it feels like there's an "elephant on his chest" and it got "hard to breathe" by 4 PM that afternoon. He said this happened over the summer at a Giants baseball game when he ate too many hotdogs. 

Patient placed on 2 LPM nasal cannula and SpO2 increased to 96%. WOB and tachypnea remained moderate. MD ordered CPAP with full face mask on 30% FiO2. RT will monitor the patient's work of breathing, heart rate, respiratory rate, and make adjustments to the CPAP as needed. Diuretics, lab tests and admission to the hospital for observation ordered. 

S (situation)

67 M, 50 pack-year smoker. Pt arrives at ED at 7:15PM. Pt says there's an "elephant on his chest" and it got "hard to breathe." 

 

B (background)

A & O x4. VS: RR 32, P 118, SpO2 90% on RA, 37.0 C temp, BP 155/110.  SOB by 4pm same day. Says also happened over summer at a baseball game after eating too many hot dogs. PMHx: HTN, CHF, and prostate Ca. Drank 3 beers, ate bacon cheeseburger, potato salad, and popcorn.

 

A (assessment)

Barrel chest, clubbing, jugular venous distention, accessory muscle use in neck, chest, and belly. Bilobar crackles and wheezing upon auscultation.

 

R (recommendation)

Pt put on 2 LPM NC and SpO2 inc to 96%. WOB and tachypnea remained moderate. MD ordered CPAP C̄ full face mask on 30% FiO2. RT will monitor WOB, HR, HR, and adjust CPAP PRN. Diuretics, lab tests and admission to the hospital for observation ordered. 

 

example 2 SBAR:

22-year-male brought in by Alameda County Emergency Medical Team to Highland Hospital after a high speed motor vehicle accident on 880 Freeway. Extended retraction from vehicle at the scene. 2 liters of fluids given with patient found hypotensive: 85 mmHg systolic blood pressure, 55 mmHg diastolic blood pressure. EMT noted lacerations on face, contusions across chest where seatbelt was worn, and believed to have multiple rib fractures. EMT indicated sustained tachypnea > 35/minute and tachycardia >140/minute. Initially, patient confused, A & O x 3. Crackles throughout, diminished breath sounds in right lower lobe. 

EMT said patient described the crash as "krekre." EMT said patient was praying "to anyone listening" on the trip to the hospital. They said there was no alcohol on the patient's breath, but found a vape pen that smelled of marijuana inside the vehicle. 

ED team stabilized the patient with one unit of Type A blood, and pressors to treat hypotension. In the ER, patient's GCS = 8, A & O x 2, AVPU score is Pain only. 

Patient is intubated with 8.0 ETT and placed on 100 % FiO2 with full ventilatory support. RT suctioned large amount of blood from oral cavity.

After an emergent CT scan, patient will be taken to surgery, and admitted to trauma ICU. 

S (situation)

Pt brought in hospital by EMT after high speed motor vehicle accident on freeway. Intubated with 8.0 ETT and on 100 % FiO2 with full vent support. Extended retraction from vehicle at the scene. EMT mentioned lacerations on face, contusions across chest at seatbelt area, believed to have multiple rib fractures. Sustained tachypnea > 35/min and tachycardia >140/minute and no ETOH, found vape pen and smell of marijuana in car. EMT stabilized pt with one unit of Type A blood to treat hypotension. 2 L of fluids given to pt. 

B (background)

22 M. VS: BP 85/55. Confused, A & O x 3. Crackles throughout, diminished BS in R lower lobe. GCS = 8, A & O x 2, AVPU score is P. Smokes marijuana.

 

A (assessment)

Blood in pt’s mouth. Monitor ETT or bloody secretions. 

 

R (recommendation)

After CT scan, will be taken to surgery, and admitted to trauma ICU.

 

example 1 SOAP:

67-year-old male, 50-pack year smoker arrives in the Emergency Department at 7:15 PM after a day watching football games on TV. Over 6 hours, he drank 3 beer, consumed a bacon cheese burger, potato salad, and popcorn. He is A & O x 4, RR 32, P 118, SpO2 90% on room air, 37.0 C temperature, systolic blood pressure 155 mmHg and diastolic blood pressure 110 mmHg. 

On visual inspection, barrel chest, clubbing, jugular venous distention, accessory muscle use in neck, chest, and belly are noted. On auscultation, bilobar crackles and wheezing.

Patient said it feels like there's an "elephant on his chest" and it got "hard to breathe" by 4 PM that afternoon. He said this happened over the summer at a Giants baseball game when he ate too many hotdogs. 

Patient placed on 2 LPM nasal cannula and SpO2 increased to 96%. WOB and tachypnea remained moderate. MD ordered CPAP with full face mask on 30% FiO2. RT will monitor the patient's work of breathing, heart rate, respiratory rate, and make adjustments to the CPAP as needed. Diuretics, lab tests and admission to the hospital for observation ordered. 

S (subjective)

Over 6 hours: drank 3 beer, ate a bacon cheese burger, potato salad, and popcorn. Pt claims feeling of "elephant on his chest" and it got "hard to breathe" by 4 PM. Mentioned it also happened over the summer at a baseball game after eating too many hot dogs.PMHx: HTN, CHF, and prostate Ca. 

 

O (objective)

67 M arrives to ED at 7:15PM, 50 pack-year smoker. A & O x 4. VS: RR 32, P 118, SpO2 90% RA, 37.0 C temp, BP 155/110.

 

A (assessment)

Barrel chest, clubbing, jugular venous distention, accessory muscle use in neck, chest, and belly. Bilobar crackles and wheezing upon auscultation.

 

P (plan)

2 LPM NC and SpO2 inc to 96%. WOB and tachypnea remained moderate. CPAP C̄ full face mask on 30% FiO2. RT will monitor the pt's WOB, HR, RR, and CPAP adjustments PRN. Diuretics, lab tests and admission to the hospital for observation.

example 2 SOAP:

22-year-male brought in by Alameda County Emergency Medical Team to Highland Hospital after a high speed motor vehicle accident on 880 Freeway. Extended retraction from vehicle at the scene. 2 liters of fluids given with patient found hypotensive: 85 mmHg systolic blood pressure, 55 mmHg diastolic blood pressure. EMT noted lacerations on face, contusions across chest where seatbelt was worn, and believed to have multiple rib fractures. EMT indicated sustained tachypnea > 35/minute and tachycardia >140/minute. Initially, patient confused, A & O x 3. Crackles throughout, diminished breath sounds in right lower lobe. 

EMT said patient described the crash as "krekre." EMT said patient was praying "to anyone listening" on the trip to the hospital. They said there was no alcohol on the patient's breath, but found a vape pen that smelled of marijuana inside the vehicle. 

ED team stabilized the patient with one unit of Type A blood, and pressors to treat hypotension. In the ER, patient's GCS = 8, A & O x 2, AVPU score is Pain only. 

Patient is intubated with 8.0 ETT and placed on 100 % FiO2 with full ventilatory support. RT suctioned large amount of blood from oral cavity.

After an emergent CT scan, patient will be taken to surgery, and admitted to trauma ICU. 

S (subjective)

EMT said pt described the crash as "krekre" and was praying "to anyone listening" on trip to the hospital.

 

O (objective)

22M brought to hospital by EMT after high speed motor accident on freeway. Extended retraction from vehicle at scene. 2 L fluids given C̄ pt found hypotensive. EMT noted VS: BP: 85/55; lacerations on face, contusions across chest on seatbelt area and believed to have multiple rib fractures. Sustained tachypnea > 35/minute and tachycardia >140/minute. Confused, A & O x 3. No ETOH, EMT found vape pen and smell of marijuana in vehicle. ED team stabilized Pt C̄ one unit of Type A blood, and pressors to treat hypotension. In the ER, pt GCS = 8, A & O x 2, AVPU score P.

 
A (assessment)

Need CT scan, surgery, ICU admission. Bloody secretions need monitoring. Crackles throughout, diminished BS in R lower lobe.

 

P (plan)

emergent CT scan, surgery and RT to monitor and assess ETT and patient's progress. 

what is a sentinel event?

an unexpected occurrence involving death or serious physical or psychological injury, or the risk of such injury, to a patient

what are some examples of sentinel events?

top 3:

• wrong site injury

• patient falls

• medication error

other examples:

• delay in tx

• unintended retention of a foreign body

• operative/postoperative complications

• suicides

• other unanticipated events

• criminal events

• perinatal death/injury

what is the importance of charting?

• protects yourself

• if you didn’t chart it, it didn’t happen