SOAPノートは必要か？

ばく

野外救急法を受講した皆さん、ちゃんとSOAPノートをフィールドに携帯ししていますか？特にWMTCのSOAPノートは書くことが多くてめんどくさい！小さな怪我でも本当にSOAPノートって必要？

SOAPノートとは、Subjective Information（主観的情報/傷病者が言ったこと）、Objective Information（客観的情報/救助者が観察したこと）、Assessment（評価）、Plan（処置計画/避難計画）のイニシャルを取ったものです。

傷病者評価システムに基づき、デジタルハンドブックと併用することで、S/Sxの情報を漏れなく収集し、それに基づく合理的な評価と処置計画を立てることに役立ちます。特に、複雑な問題であればあるほど、よく整理されたSOAPノートは適切な評価と避難計画に効果的です。しかしながら、全ての傷病に、時間のかかるSOAPノートが本当に必要か疑問に思っている人も多いのではないでしょうか？

問題が重大で、複合的であれば、あなたを法的に守る根拠資料としてもSOAPノートは必要です。一方、小さな問題、例えば、靴擦れ、軽度の捻挫、切り傷などで、重大な問題に発展せず、避難の必要性がなければ、必ずしもSOAPノートの価値を活用するまでもない時もあります。ただ、小さな問題が将来の大きな問題、例えば虫刺されがアナフィラキシー、頭のちょっとした創が脳震盪、意識のある溺れが肺水腫などに発展するどうかは、誰にもわかりません。

そこで、小さな問題であれば以下の2通りの使い方を提案します。

1.全ての傷病についてSOAPノートを書き上げましょう。慣れてくれば数分で書き上げることができるます。最終的に不要になることもあるかもしれませんが、あなたを法的に擁護する根拠資料となります。また、安全管理上、ほとんどの団体で事故の記録、報告をすることが義務付けられているでしょう。

2.基本的な情報をノートに記録します。名前、主訴に関する主観的情報、主訴に関する客観的情報、現在の問題、処置計画。もしS/Sxが悪化し、注意が必要になったらSOAPノートに転記し、SOAPノートによる記録を開始します。

SOAPノートを繰り返し使うことで、BLSの問題や、S/Sxから、現在の問題、予想される問題、避難計画まで、頭の中で、一連の流れを想像できるようになります。そのためには、やはり軽微な事故でSOAPノートを書くトレーニングが必要でしょう。万が一の大きな事故に備え、日々の積み重ねが大切です。日々の積み重ねがあるからこそ、大事故を予想して、未然に防ぐことができるのでしょう。

正しくSOAPノートを書くためには、デジタルハンドブックを参照し、WFA/WFRコースに参加してトレーニングを受けることが必要である。

Author: Paul Nicolazzo/ Translator: Taito Okamura

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