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SOAP NOTE

Patient
Name:________________________________________________________________________

Date:__________ Age: Sex:_

SUBJECTIVE: (Mechanism of injury (MOI), chief complaint (C/C))

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

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

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:____________________________________________

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