Health Science Core Chapter 12 and SOAP Writing

McFatter Technical Center

Emergency Medical Technician - Basic

Chapter 12

Determining Meaning

• Prefix – word element placed in front of a root to modify its meaning

• Suffix – word element placed at the end of the root to modify its meaning

• Root word – main part of a word

Common Prefixes

• A-, an- : absent, deficient, without• Bi- : two• Brady- : slow• Contra- : opposite, opposed,

against• Di- : two• Fore- : in front• Hemi : half• Hyper- : excessive, above,

increase• Hypo- : below, deficient, under

Common Prefixes

• Mal- : abnormal, bad• Micro- : small• Mono- : one• Multi- : many• Para- : beside, beyond,

apart from• Peri- : surrounding • Post- : following after• Pre- : in front of, before

Common Prefixes

• Semi- : half• Sub- : under, below• Super- or Supra- : over, above• Sym- : with, together• Tachy- : fast, rapid• Trans- : across• Tri- : three• Ultra- : excess, beyond

Common Suffixes

• -algia : painful• -dynia : painful, difficult, bad• -ectomy : surgical removal,

excision• -emia : blood• -graph : instrument for recording• -graphy : process of recording• -itis : inflammation• -logy : science of, study of

Common Suffixes

• -osis : abnormal condition• -pathy : disease• -pnea : breathing• -rhea : flow or discharge• -scope : instrument used to

examine or look into a part• -sis : condition or process• -tomy : cutting into, incision

Abbreviations

• AAOx3 – Alert and orientated times person, place, and time/date

• abd – abdomen• ac – before meals• AMI – acute myocardial infraction• amt – amount• ant – anterior• ASA – Aspirin• BM – bowel movement• BP – blood pressure• BS – blood sugar

• BVM – Bag valve mask• CA – cancer• CC – chief complaint• CHF – congestive heart failure• CNS – central nervous system• c/o – complaining of• COPD – chronic obstructive pulmonary disease• DNR – do not resuscitate• DOA – dead on arrival

Abbreviations

• ECG – electrocardiogram• EENT – eye, ear, nose, and throat• EKG – electrocardiogram• ETA – estimated time of arrival• Fx – fracture• H/A - headache• HEENT – head, eyes, ears, nose, and throat• HTN – hypertension• HX – history• IM – intramuscular• IV – intravenous• IVP – intravenous push

Abbreviations

• kg – kilogram• LLQ – left lower quadrant• LOC – level of consciousness• LR – lactated ringers• Lt – left• LUQ – left upper quadrant• mg – miligram• MI – myocardial infarction • ml – milliliter

Abbreviations

• NC – nasal cannula• NPO – nothing by mouth• NRB – non-rebreather mask• NS – normal saline• NTG - nitroglycerin• OD – overdose• pc – after meals• PERL – pupils equal and reactive to light• po – by mouth• PRN – whenever necessary or as needed• PTA – prior to arrival

Abbreviations

• RLQ – right lower quadrant • RUQ – right upper quadrant• SOB – short of breath• TKO – to keep open• Y/O – years old• V.S. – vital signs• w/o – without• WNL – within normal limits

Abbreviations

SOAP Report Writing

Why do we document patient care?

• Information for hospital staff• Quality assurance or

statistics• Legal record of our

observations and care which could later be used in a courtroom

• Professional accountability.

Tips for Documentation

• Be honest, complete and accurate

• Reports should be written objectively.

• Legible handwriting• Correct spelling• Use of standardized

abbreviations • Never falsify information

Tips for DocumentationObjectivity

• Do not write your opinions or judgments about the patient

• Be careful to avoid terminology which could be construed as slander/libel like drunk, alcoholic, druggie.

• Avoid placing blame for any potential litigious circumstances, Instead site direct quotes of the patient and witnesses.

Documentation Format

• S – Subjective• O – Objective• A – Assessment• P – Plan

SubjectiveWhat was told to you

1. Describe the patient like age and gender.

2. Chief complaint.

3. What the patient tells you in description

4. SAMPLE questions

5. What other people at the scene tell you like other responders, witnesses, or police.

ObjectiveWhat you see, hear, and feel.

1. Initial impression of the patient like location and position.

2. General observations and other noteworthy information such as environmental conditions or patient behavior

3. Vital signs and level of consciousness

4. Physical exam findings

5. Head to toe

AssessmentYour Diagnosis

• Diagnostic conclusion(s) based on the patient's chief complaint and your physical exam findings.

• Qualify each with "possible" or "rule out.“• May have more than one diagnosis

Plan What you did

• Should be chronological• What was done prior to your arrival • What was done for the patient • How patient responded to the treatment• How care was discontinued or transferred• Patient’s condition at departure

Specific Documentation Concerns

Specific Documentation ConsiderationsCrime Scene

• Don't walk through pools of blood or contaminate evidence

• Reports on these cases should be prepared with additional care for you may have to testify in court

• Document statements from the patient very precisely

• Document “chain of evidence” when turning over evidence

Specific Documentation ConsiderationsHomicide

• Wait for police to secure scene• Advise an officer of entering scene • Avoid tunnel vision and take a wide

view of the scene as you enter• Keep the number of people

entering the crime scene to a minimum

• Leave all disposable equipment on the victim and document what procedures you did

Specific Documentation ConsiderationsChild and Elderly Abuse

• With emotional challenges it is important to maintain professional demeanor

• Note in report all unusual marks, bruising, burns, healing wounds, evidence of dehydration, or any abnormalities noted on exam.

• Contact abuse hotline and note on report

References

• Stevens, Kay, and Garber, Debra. Introduction to Clinical Allied Healthcare. 2nd ed. Clifton Park, New York: Thomson Delmar Learning, 1996.

• Maggiore, Ann and Gurchiek, David. How to document the unthinkable. JEMS.