What Is a S.O.A.P. Note?

Wilderness First Aid is known for an abundance of acronyms. To hear two Wilderness First Aid providers confer on treating someone might sound like an Alien dialect at times. But one of the most important tools (and acronyms) we have and use in Wilderness First Aid is the trusty S.O.A.P. note.

 

A S.O.A.P. note refers to an organizational system for information that a Wilderness First Aid provider has gathered over the course of a full Patient Assessment. The information is put into a written or sometimes verbal format divided into four sections: Subjective, Objective, Assessment, and Plan or S.O.A.P. for short.

 

• Subjective information refers to the things your patient tells you that you can’t necessarily confirm yourself. This information is often qualitative in nature. Things like symptoms, events you didn’t witness, and medical history are all types of information that you have only your patient’s word to go on. It is important to label this information as subjective because it may be misleading, incomplete, or flat out false depending on the patient.
• Objective information refers to the things that you yourself can observe and are often quantitative. Things like heart rate, respiratory rate, bruising, swelling, or angulation are examples of things that can fall under this category. Because this is information obtained through physical observation, we can often track trends in this information. So a Wilderness First Aid provider will often organize Objective information, like vital signs, with time stamps and room for multiple sets of numbers or observations.
• The Assessment portion of a S.O.A.P. note is where you compile your problems. A good Wilderness First Aid provider will systematically go through the Subjective and Objective portions of their S.O.A.P. note to list every single potential problem here—no matter how big or small. Things like “unusable lower leg injury, steep mountainous terrain, nightfall 2 hrs away” will end up going in here. It is important to be thorough in your problem list because it will inform your actions later.
• Finally, the Plan portion of your S.O.A.P. note is where you come up with a course of action. Your Plan phase should have an action or treatment that addresses each of your problems. If there is a problem that isn’t explicitly addressed in your Plan, then you have not finished this step. In this phase, you will decide important things like whether to stay in the backcountry or get out, what resources you require, and what your ongoing treatment will be for a patient that is going to spend extended time away from advanced medical care.

Compiling this information in an organized way is crucial to making sure you are responding to a backcountry emergency logically and responsibly. It is also a record of what you have done, and what treatments a given patient has received. Remember that most backcountry illnesses and injuries are going to involve other medical professionals—whether it’s a check-in with a doctor after a trip or a full-on team of Search and Rescue EMTs deploying into the backcountry to help. The S.O.A.P. note can be an incredibly handy way to pass off crucial information quickly and get medical personnel up to speed.

 

Just imagine for a second that you are a Search and Rescue team member and you are about to respond to an injured person in the backcountry. It often takes hours and sometimes even days for Search and Rescue to get to a patient in the backcountry. Now imagine the only information you have is that you’re responding to an injured person who fell off of a cliff. The list of potential injuries is endless—anywhere from life-threatening to mundane. You have no idea what to expect or if there is any specific first aid equipment you should pack with you.

 

Now put yourself in the same position but you’ve received a verbal S.O.A.P. note from the patient’s friend who is Wilderness First Aid certified and has completed a full patient assessment. The patient has an unusable left wrist injury. The cliff was approximately 5 ft tall. The patient has had normal and stable vitals over the last hour and a half. The patient needs to leave the backcountry. Wilderness First Aid provider is requesting advanced medical personnel to rule out an injury to the spine. And finally, the patient is protected from the elements, and splinting is underway. As a responder, wouldn’t you love having all of that information communicated in a clear and concise way before you deploy? Wouldn’t you feel more prepared to help?

 

Without properly understanding the tool, a S.O.A.P. note might feel like homework or tedious paperwork. And I get it. No one likes paperwork. Most of the time it’s the reason we escape to the outdoors in the first place! But in the event of a medical emergency in the backcountry, meticulous documentation and communication—facilitated by a proper S.O.A.P.—is essential to ensure all parts of a response are executed appropriately. A Wilderness First Aid course at CPR Seattle trains rescuers how to effectively create a S.O.A.P. note. Questions? Feel free to call us at 206-504-3280, or email us at cpr@cprseattle.com.

 

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Published on January 6, 2022