| Copyright 2002
Wilderness Drum, Inc.
All rights reserved Wilderness Emergency Care
Documentation
Steve Beyer Wilderness and survival people often engage in lengthy debates about what should and should not be included in a medical kit. Very few people mention what I think are two of the most important tools you can bring with you – a pen and a pad of paper. Keeping good documentation is important for several reasons. - Writing things down in an orderly and organized way can be a help to clear thinking in an emergency situation.
- Writing things down allows you to keep careful track of your patient's course. Knowing just what your patient's vital signs were one hour ago, and then again half an hour ago, for example, will let you know more clearly than your fallible memory whether or not he is slipping into shock.
- At some point, rescuers or definitive care providers, in order to take over the care of your patient, will need to know just what happened, what you observed, what you did, and what medications you gave. Your written notes are invaluable for this purpose.
- Finally, your notes will help you recall later what happened, what you did, and why you did it. This could be for your own review, in order to learn what you did right and what you might have done differently; or it could be for the review of others, in a determination of whether you properly fulfilled your responsibilities to your patient. Remember the golden maxim – if you didn't document it, you didn't do it.
How should you keep these notes? The SOAP-notes method has become almost universally accepted as a simple, effective way to organize your patient documentation. The acronym SOAP stands for Subjective – what the patient tells you; Objective – what you yourself observe; Assessment – what you think is going on; and Plan – what you intend to do. In more detail: - Subjective includes a statement of the circumstances of your treatment, the age and sex of the patient (sometimes called the "demographic description"), a Chief Complaint, and a significant history. The Chief Complaint could be anything from diarrhea to a crushed limb. In trauma cases, the history would include a description of the mechanism of injury, the object causing the injury, and the time and circumstances of the injury. Also part of the history would be the presence of any allergies or drug sensitivities, and – importantly – the patient's tetanus immunization status.
- Objective reflects the result of your patient examination – the patient's vital signs; the presence, location, and size of any wounds; the presence and description of any tendon, nerve, vascular, bone, or organ injury; the level of wound contamination; and the presence of infection.
- Assessment usually consists of a list of the problems you believe exist. You might suspect mushroom poisoning; you might conclude the patient has a snakebite injury; you might determine he has a broken ankle. You should also include any other contributing factors. Do not forget that, in the wilderness, problems are very often compounded by hypothermia and lack of adequate hydration. And remember – you are not a doctor; therefore you do not diagnose; you assess.
- Plan consists of a list of things you plan to do. If there is more than one problem, each item in Assessment should have its own entry under Plan. For example – (A1) Laceration to right inner thigh (A2) Loss of blood (P1) Clean and dress wound (P2) Treat for shock. In a wilderness setting, the Plan should almost always include an item called Monitor – that is, what you are going to watch for. For example, you might also have (P3) Monitor for infection.
In a wilderness setting, your notes should also include a description of the weather and terrain, a list of available resources, and an estimate of evacuation time. At each examination, you should also determine, update, and record an evacuation priority. There are several systems for documenting an evacuation priority. One fourfold system describes evacuation priorities as Hasty, Urgent, Routine, or Delayed. Another system gives three primary Status Codes – Status I = alive and well, capable of self-evacuation; Status II = ill or injured, requiring evacuation and medical treatment; Status III = dead. Status II is often divided into five sub-descriptions, from Status IIA = ill or injured but able to walk or climb out with assistance to Status IIE = seriously ill or injured with death likely before evacuation completed. Needless to say, when using radio communications, you should always be very careful to protect the confidentiality of your patient. |
