Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

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Section I: General Principles

In the ideal setting your SOAP note would be a well-organized written document, but we real- ize that this is impossible to do in a life raft or on a mountainside during a storm. But, it is just these challenging situations that are most in need of critical thinking and an organized response. Reviewing the SOAP, especially the assessment and plan, even if it is all done in your head, can help render order from chaos, improve commu- nication, and save lives. Practice it. Use it.

Chapter 3 Review: Patient Assessment and the SOAP Format

• The patient assessment system consists of the scene size-up, primary assessment, and secondary assessment. • The scene size-up includes identifying the number of patients and available resources, hazards to rescuers and patients, and the mechanism of injury. • The primary assessment identifies life-threatening problems with the circulatory, respiratory, or nervous systems requiring immediate treatment. • Basic and advanced life support is the immediate care rendered to stabilize or correct serious prob- lems identified by the primary assessment. • The secondary assessment includes a more complete patient examination and medical history to identify all relevant problems. • The SOAP format is used to organize and present information obtained by the scene size-up and patient assessment.