During this step you transition to long-term care, which means caring for the patient’s ongoing treatment and safety (if, for instance, you’re waiting for evacuation and will be in the backcountry for an extended period) or handing the patient off to medical professionals (comprehensive information will help them do their job). Use a written SOAP note—an acronym for an incident’s subjective and objective elements, your assessment, and your treatment plan.*
>> Subjective Include the patient’s age, sex, and a description of the incident as the victim describes it. Include the chief complaint, spinal injury assessment, and responsiveness.
>> Objective Detail your evaluation. How did you find the patient? Include vital signs, SAMPLE history, and pertinent negatives (e.g. “Patient denies allergies to any medications.”)
>> Assessment Prioritize a list of injuries and conditions that may complicate rescue and evacuation or need monitoring.
>> Plan Outline a strategy for managing patient needs over time. Consider potential problems and environmental
factors, like keeping an immobile patient warm and dry.