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Advanced Documentation

STEMI with Cardiogenic Shock

How this exercise works

Sort ALS narrative elements into SOAP sections or discard non-clinical filler. Advanced calls include more objective data, interventions, and reassessment findings.

Fundamental concept

Building paramedic PCRs that capture interventions, reassessment, medical direction, and critical time stamps for ALS calls.

Read: Advanced ALS Documentation & SOAP Narratives →

Scenario

58-year-old male, crushing chest pain 45 minutes, diaphoretic, pale. 12-lead shows anterior STEMI.

Dispatch: chest pain, priority 1. Partner established IV while you acquired 12-lead. Aspirin given per protocol. 18-minute transport to PCI center.

Report statements

Drag each sentence into the correct SOAP section, or into the trash if it does not belong in the chart.

Crew discussed playoff game during transport.
Alert, pale, diaphoretic; lungs with bibasilar crackles.
Patient complained about hospital food on last admission three years ago.
STEMI alert, cautious fluids, norepinephrine per protocol, emergent PCI transport.
12-lead: ST elevation V2–V5; BP 86/52, HR 102, SpO₂ 91% on 4 L.
Denies prior similar pain; history of hypertension and hyperlipidemia.
Patient reports substernal pressure radiating to left arm since mowing lawn.
Anterior STEMI with cardiogenic shock physiology.

Trash — not charted

0

Drop useless or irrelevant statements here

S — Subjective

0

Drop statements here

O — Objective

0

Drop statements here

A — Assessment

0

Drop statements here

P — Plan

0

Drop statements here