Scenario
Construction worker found dizzy at job site on hot day, now alert and oriented.
Ambient temperature approximately 38°C. Coworkers moved him to shade.
Report statements
Drag each sentence into the correct SOAP section, or into the trash if it does not belong in the chart.
Complains of dizziness, nausea, and muscle cramps.
BP 102/68, pulse 108, RR 18, temp 38.6°C.
Patient reports working outdoors 6 hours without adequate fluids.
Heat exhaustion without altered mental status.
Cool patient, oral fluids if tolerated, transport for evaluation.
Job site supervisor signed paperwork at 0800.
Skin cool and clammy, pupils equal, lungs clear.
Hard hat was yellow with company logo.
Trash — not charted
0Drop useless or irrelevant statements here
S — Subjective
0Drop statements here
O — Objective
0Drop statements here
A — Assessment
0Drop statements here
P — Plan
0Drop statements here