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SOAP NOTE
Patient
Name:________________________________________________________________________
Date:______________ Age:________ Sex:_____
SUBJECTIVE: (Mechanism of injury (MOI), chief complaint (C/C))
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OBJECTIVE: (Patient exam findings, Vital Signs, SAMPLE History)
Vital Signs:
Time:
LOC:
HR
RR
Skin (C/T/M)
Patient Exam: Describe locations of pain, tenderness, injuries, Pertinent negatives
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SAMPLE:
Signs/Symptoms:
Allergies:
Medications:
Pertinent Medical History:
Last Oral Intake:
Events leading to accident:
ASSESSMENT: (problem list)
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
4.____________________________________________________________________________
5.____________________________________________________________________________
PLAN: (plan for each problem on list, evac route, bivouac location)
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
4.____________________________________________________________________________
5.____________________________________________________________________________
Form completed by:____________________________________________