Q: Medical Care Documentation

Q: I am a camp director who requires our staff to have medical training. If they do render care, what if anything should be documented?
A medical record or any similar form of documentation is more that just an effort by medical practitioners to protect themselves against a law suit. It provides a contemporary account of what happened and what has been done. When care and transport will be lengthy, the record can provide a chronological, objective look at what you thought and did and how things have evolved.

Download SOAP pdf

We advocate recording the information in the SOAP format because it forces clarity of thought. A good SOAP note is simple to generate and results in a logical and organized document.

In the acronym, the letter S is for subjective or the story of what happened and the person’s symptoms; O is for objective things observed, felt or measured during the exam; A is for assessment of the problems/working diagnosis, what the examiner thinks is going on and could evolve over time based on S and O – this should also include the potential logistical problems of transport; P is for plan or what are you going to do about each problem. Don’t forget the logistical dilemmas. This can have a big impact on what you do and how to utilize resources.

I personally believe that a note of some kind should be made any time medical care is rendered and most particularly for those problems that will require follow-up either on the trip or afterwards. This chronology should include:

  1. What happened, including a description of an accident or events leading up to the problem and the symptoms that have evolved.
  2. A list of medications, allergies, and important medical problems.
  3. Pertinent finding on the examination.
  4. A list of what one thinks is wrong, trying to be as accurate as one can. It is more important to be clear about the urgency of a problem than about the precise diagnosis. Is this really an emergency?
  5. Formulate a list of anticipated problems – how things could get worse and what new problems may evolve.
  6. A plan of action and what one has actually done. Don’t forget logistics of evacuation.
  7. A periodic update describing any changes in condition and/or modification in the plan.

Why bother writing all of this down? As with any other observation, the precision of one’s recollection fades over time. Taking the time to record information and then analyze it will generally clarify what is going on and lead to a better plan. When it comes to understanding what is happening and what to do about it, objectivity always trumps one’s gut. This is particularly true for relatively inexperienced practitioners.

What should you do with this information? If care is to be transferred, ideally, copy the salient points for the receiving person and retain the original for yourself (or vice versa if it will be easier). Although these kinds of notes are not legally subject to HIPPA (rules and regulations mandating how medical professionals and institutions must safeguard patient information), it is important to protect a person’s privacy. Only share patient information with healthcare providers who really need to know.

Bottom line: Record relevant information including your impression, treatment and the person’s condition over time. It is important to outline concerns for evolving problems and solutions to evacuation challenges. Be sure to limit access to this information to people who really need to know.

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