[pct-l] SOAP Note For Trail Use

[mlissner at aidshike.org (Michael Lissner)]

I'm fairly sure there's an acronym tab on the bottom of the note, but...

LOC - Level of Consciousness. AVPU (pronounced Av Poo) Alert (able to 
answer questions such as, what is your name, where are you, what did you 
just eat), Verbal (able to talk, doesn't make any sense), Painful 
(responsive only to sharp pain such as a rough pinch), Unconscious 
(alive, but totally unresponsive to anything).

HR/Min - Heart Rate Per Minute

RR/Min - Respiratory Rate/Minute

SCTM - Skin Color, Temperature, Moisture (there's a set of acronyms to 
answer this one, but usually, "white, cold, moist" or something like 
that works).

BP - Blood Pressure if you feel a pulse in their foot, BP isn't too low, 
it's worth noting that.

Pupils - What you're looking for here are pupils that are PERRL 
(pronounced Pearl) - Pupils Equal, Round, Responsive to Light

Temp - Body Temperature - Detail is good here, but nobody carries a 
thermometer so, Hot, cold, normal whatever.

Hope that helps.

-patch



Tortoise wrote:

> Ok, "Doc". for those of us not in the know, what do these 
> abbreviations stand for?
>
> LOC (AVPU)
>
> HR/min
>
> RR/min
>
> SCTM
>
> BP            (blood pressure ?)
>
> Pupils            (eye pupils ?? what observation, pupils equal in 
> size, responsive to light???)
>
> Temp.
>
>
> ----------
> Tortoise
>
> I switched to Mac OSX rather than fight Windows
> Using Mozilla Thunderbird  http://www.mozilla.org/products/thunderbird/
>
> Michael Lissner wrote:
>
>> For those of you that know what one is, I just resurrected my 
>> ultralight SOAP note and put it on aidshike.org.
>>
>> The place to look is 
>> http://www.aidshike.org/assets/spreadsheets/SOAPA_note.xls
>>
>> For those of you that don't know what a SOAP note is, a SOAP note is 
>> essentially what those that arrive first to the scene of an emergency 
>> use to collect their thoughts and observations in an organized, 
>> complete and legally presentable fashion. These are said to be 
>> incredibly useful documents when you're not at your sharpest state of 
>> mind, and I highly recommend that anybody with first aid training 
>> consider carrying one (or two) of these in their first aid kit 
>> (luckily I haven't had to use one).
>>
>> This SOAP note differs from your standard one for a couple of 
>> reasons. One, because it is designed to fit on half a sheet of paper 
>> rather than a full sheet, it's ultralight. Two, it's designed for 
>> outdoor use rather than the urban environment, so it includes vital 
>> signs that might not be as important when medical care is an 
>> ambulance away; things that might hint at slow developing problems 
>> like rising intercranial pressure (ICP).
>>
>> Anyway, hope this helps to keep everybody safe, and I humbly 
>> apologize for the cross posting.
>>
>> -Dr. Patch O'Malley IV
>>
>> PS In trail name only do I wear the prefix "Dr"
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>