Patient SOAP Note
LEAD RESCUER’S NAMEName
PATIENT INFORMATION
Age

Subjective Information = What the patient tells you

Objective Information = What you see

SYMPTOMS = Describe onset, cause, and severity (1-10) of chief complaints.

PHYSICAL EXAM = Look for discoloration, swelling, abnormal fluid loss, & deformity.
Feel for tenderness, crepitus, & instability. Check ROM & CSM.

TimeTime

WeightMale

Address

FemalePhone
DateTime

Contact PersonPhoneDESCRIBE MOI

TraumaEnvironmental

MedicalIf Trauma, tell a brief story that addresses speed, dispersal of KE, & location of impact.

ALLERGIES = Local or systemic, cause, severity and treatment.
MEDICATIONS = prescription, over-the-counter, herbal, homeopathic, & recreational.
DRUG

DESCRIBE WEATHER CONDITIONSREASONDOSE

CURRENTYes / NoYes / No

Notes

Temp ___________

Sun

PATIENT FOUND

Partly Cloudy

Right Side
Left Side
Front
Back
Lying
SittingStanding

Overcast

INITIAL PX

No Respirations
Unstable Spine
Blocked Airway

Wind

Rain

Snow

VITAL SIGNS = Get a baseline, then record changes. Record normal VS if known.
PAST RELEVANT MEDICAL HISTORY = Relate to MOITimePulse

Resp

O2 SatBPSkin

Temp

AVPU

NormalNo Pulse
Vomiting
Severe Bleeding
V P U on arrival

INITIAL TREATMENTLAST FOOD & FLUIDS = Intake & Output
H2OCalories

Electrolytes

Urine ColorUrine Output

Stool

EVENTS = Patient’s description of what happened.

Memory LossYes / No

FOCUSED SPINE ASSESSMENTTime
Direct Pressure
Pressure Dressing ______________
Tourniquet ______________
Chest Compressions
Rescue Breathing
Abdominal Thrust
Suction
C-CollarStabilize Spine
Remove Wet Clothes
Hypothermia Package
Cool Pt
GlucoseMed __________________________
Shelter
Evac 1 2© 2010 the Wilderness Medicine Training Center		PassFailYes NoYes No
Reliable Patient
Squeeze 1st & Ring Finger
Spine Pain
Press Down on Hand or Fingers
Spine Tenderness
Press Up on Foot or Big Toe
Shooting Pain
Press Down on Foot or Big Toe
Distinguish between Pinprick & Light Touch on hands and feetwildmedcenter.com

Assessment = What you think is wrong

POSSIBLE PX

TIME

Traumatic Px

Unstable Spine
Concussion /Trunk Injury

CURRENT PXANTICIPATED PX

Plan = What you are going to do

FIELD TREATMENT

Additional Information

MONITORRESCUER 1 Name

TimeAgeE-mailMaleAddress

ICP

Phone
Cell
Organization

Respiratory Distress

RESCUER 2 Name

Volume Shock

Unstable Extremity Injury

AgeE-mailStable Extremity Injury
WoundsMale

Address

FemalePhone

Environmental Px

Cell

Dehydration / Low Sodium

Organization

Cold / Hypothermia

WITNESS 1 Name

Frostbite / Burns

E-mailHeat Exhaustion / Stroke
Local / Systemic Toxin

Age
Male

Address

Local / Systemic Allergy

FemalePhone
Cell

Near Drowning

Relationship

Acute Mountain Sickness

WITNESS 2 NameLightning

SCUBA / Free DivingAge

E-mailMedical Px

MaleAddress

Circulatory System Px

FemalePhone
Cell

Respiratory System Px
Nervous System Px

Relationship

Endocrine System Px

WITNESS 3 Name

Genitourinary System Px

E-mailGastrointestinal System Px
Ear Px

AgeMaleAddressEye PxFemalePhone
Cell

Tooth & Gum Px

Relationship

Skin Px

EMERGENCY CALL LOG

Infectious Disease

ADDITIONAL PATIENT NOTES

FemaleEVACUATION PLAN

Time

Level
1 2 3 41 2 3 41 2 3 4Time

None
None
None

Self
Self
Self

AssistAssistAssist

TypeCarryCarry
Carry

LitterLitterLitter

VehicleVehicleVehicle

Number

Person/Organization