A field-ready structure for a clear clinical story, with 15 complete examples across common call categories.
Begin with age, gender and living situation: HOME (private home), IL (independent living), AL (assisted living) or RC (residential care). Then document the chief concern, onset, history, associated symptoms, pertinent negatives, relevant history, medications and source of collateral information.
Document the primary survey first, then the patient’s location and position on EMS arrival, general appearance, LOC/GCS, serial vital signs, focused review of systems, physical findings, ECG/BGL/SpO₂/ETCO₂ when relevant and objective treatment response.
List the three leading differential considerations in order. State clinical severity and whether the patient is improving, worsening or unchanged. Avoid claiming diagnostic certainty beyond the available prehospital assessment.
Record treatments, medications, doses, routes, times and procedures; monitoring and reassessment; response; transport priority and destination; pre-alert; and transfer of care. Explain refusals, delays or deviations with the clinical rationale.
Differential considerations: 1) acute coronary syndrome, 2) aortic pathology, 3) gastrointestinal or esophageal pain. Ongoing high-risk chest pain without current hemodynamic instability.
RespiratoryDifferential considerations: 1) acute COPD exacerbation, 2) lower respiratory infection or pneumonia, 3) acute heart failure. Moderate respiratory distress with hypoxemia.
NeurologicDifferential considerations: 1) acute stroke, 2) intracranial hemorrhage, 3) metabolic stroke mimic. Time-sensitive focal neurologic deficit.
GastrointestinalDifferential considerations: 1) appendiceal or other intra-abdominal inflammation, 2) gynecologic pathology, 3) renal or ureteric pathology. Focal abdominal pain without current shock.
Genitourinary / renalDifferential considerations: 1) electrolyte disturbance including hyperkalemia, 2) volume imbalance, 3) intercurrent gastrointestinal illness. Missed dialysis with cardiac symptoms.
Endocrine / metabolicDifferential considerations: 1) medication-associated hypoglycemia, 2) occult infection causing reduced intake, 3) other metabolic or neurologic cause. Symptomatic low glucose.
Musculoskeletal / traumaDifferential considerations: 1) proximal femur or hip fracture, 2) pelvic injury, 3) occult intracranial injury given head strike and anticoagulation. No current neurovascular compromise.
InfectiousDifferential considerations: 1) sepsis from urinary or other infection, 2) dehydration with delirium, 3) medication or metabolic cause. Acute delirium with concerning perfusion trend.
Integumentary / woundDifferential considerations: 1) cellulitis or wound infection, 2) deep-vein thrombosis, 3) deeper soft-tissue infection. Local infection features without current shock.
Mental healthDifferential considerations: 1) acute suicidal crisis in depressive illness, 2) substance-related mood or judgment change, 3) medical contributor to behavioural change. High safety concern because of stated plan.
ToxicologyDifferential considerations: 1) opioid poisoning, 2) mixed substance poisoning, 3) intracranial or metabolic cause of reduced LOC. Immediate ventilatory compromise.
Obstetric / gynecologicDifferential considerations: 1) secondary postpartum hemorrhage, 2) retained products or uterine infection, 3) other gynecologic bleeding. Active bleeding with volume-loss symptoms.
PediatricDifferential considerations: 1) viral lower respiratory illness, 2) pneumonia, 3) bronchospasm. Respiratory distress without current exhaustion or altered LOC.
PalliativeDifferential considerations: 1) expected progression of terminal lung disease, 2) pleural effusion or infection, 3) pulmonary embolic or cardiac event. Symptom crisis in context of documented goals.
General medical / geriatricDifferential considerations: 1) infection with delirium, 2) dehydration or electrolyte disturbance, 3) medication adverse effect. Acute functional decline without a confirmed cause.
Even within SOAP, tell a clear story from dispatch through transfer of care.
Include negatives that influence your assessment or disposition, not long lists of unrelated negatives.
Record the initial finding, intervention, reassessment and response.
For older adults and people with cognitive, neurologic or functional needs, document baseline cognition, mobility, speech, oxygen and supports.
Direct quotations can clarify refusals, safety statements, threats and unusual history.
State whether information came from the patient, family, staff, witnesses, medication packaging or records.
