Guerilla Clinic Basics; how to record patient care, the SOAP note

One aspect that is always under-represented in the prepping community is how to handle long-term medical care and chiefly, medical documentation. Currently, most hospitals use some sort of digital record-keeping system commonly referred to as an EMR (electronic medical record) and most do not have good things to say about them. We had our own version in the Military called AHLTA and AHLTA-T for deployment use. My experience with them was not pleasant at all. For the most part, we track medical treatments with the ever-trusty SF600 or Chronological Record of Medical Care. Most who have spent time in any branch have had their medical care documented on this form. It’s pretty blank except for a space at the bottom for demographic info.

This form allows medical personnel to fill out what is called a SOAP note to document the care provided by them. A SOAP note is a standard way to handle basic patient care. SOAP stands for; Subjective, Objective, Assessment, and Plan.

The subjective portion is the part where we write down answers to questions we ask you. It is called subjective because it is what you are telling us without any interpretation. This is where we ask questions like “when did this start?” or “rate your pain on a scale of 1-10”. The questions, therefore, have to be pretty specific to make sure we are getting what we need and not extra stuff that we don’t.

The Objective is where we run simple tests like having you squeeze our fingers or push against our hands. This is also where we record basic vital signs. This helps weed out some stuff from just what you tell us (the reason why WebMD gives you such crazy answers to your symptoms is that it is only using what you tell it)

The Assessment is just that, where we make a WAG (wild-ass guess) as to what issue you have since we are not doctors and can not diagnose people.

The Plan is what we are going to do to make it all better (the best we can). Usually, it is a combination of medication, further tests, patient education, and a “return to the clinic if symptoms worsen”. This part can be as basic or detailed as you want. It’s up to your level of experience and the resources you have available.

The SOAP note seems pretty crazy, but with practice can actually be quite simple.

If you are looking for practice on SOAP notes, and for more information about the non-trauma side of things, check out the Stuck Pig Medical Patreon. We have a class coming up this Wednesday all about SOAP notes.