What should be included in the SOAP note for a patient with a dislocated knee, blood pressure of hypertension, and given fentanyl and toradol?

SOAP Note Guidelines for a 16-Year-Old Male with Knee Dislocation

For a 16-year-old male football player with left knee dislocation, elevated blood pressure, and administration of fentanyl and toradol, the SOAP note should comprehensively document the injury, vital signs, pain management, and treatment plan to ensure optimal outcomes and prevent complications.

Subjective Section

• Document the mechanism of injury - specifically how the knee dislocation occurred during football play, including any contact or non-contact mechanism 1
• Record the patient's description of pain using a numerical pain scale (0-10) before and after medication administration 2
• Note the time of injury and any immediate interventions attempted on the field 2
• Document any previous history of knee injuries, dislocations, or other musculoskeletal problems 1
• Record any associated symptoms such as numbness, tingling, or inability to move the foot/ankle 1

Objective Section

• Document vital signs with special attention to blood pressure (144/81) and trending of BP after pain medication administration 2
• Record medication administration details:
  • Fentanyl 100mcg at 1359
  • Toradol at 1558 2
• Document physical examination findings of the knee:
  • Appearance (deformity, swelling, ecchymosis)
  • Neurovascular status distal to injury (pulses, capillary refill, sensation, motor function)
  • Joint stability assessment after reduction 1
• Document the reduction procedure if performed in the emergency department 2
• Include results of any imaging studies (X-rays, CT, MRI if available) 1

Assessment Section

• Primary diagnosis: Left knee dislocation 1
• Document the specific type/direction of dislocation if known 1
• Note associated injuries including:
  • Ligamentous injuries (cruciate and collateral ligaments)
  • Vascular status (critical to assess for all knee dislocations)
  • Nerve injuries
  • Fractures if present 1
• Include assessment of pain control effectiveness 2
• Document hypertension assessment (likely pain-related vs. other causes) 2

Plan Section

• Immediate management:
  • Immobilization method (brace, splint) 2
  • Weight-bearing status and mobility restrictions 2
  • Pain management plan (continuation or adjustment of medications) 2
• Diagnostic plan:
  • MRI to assess ligamentous injuries if not already performed 1
  • Vascular studies (ankle-brachial index, CT angiography, or formal angiography) to rule out vascular injury 1
• Consultation recommendations:
  • Orthopedic surgery for definitive management 2
  • Vascular surgery if any concern for vascular compromise 1
• Follow-up plan:
  • Timing of orthopedic follow-up
  • Physical therapy referral 2
• Patient education:
  • Warning signs requiring immediate return (increased pain, numbness, color changes) 2
  • Expected recovery timeline 2
• Monitoring plan for blood pressure if elevated readings persist 2

Special Considerations

• Knee dislocations represent true orthopedic emergencies due to the high risk of vascular injury, which can occur in both obvious dislocations and "reduced" bicruciate ligament injuries 1
• Pain management should be aggressive but monitored, especially with opioids in adolescent patients 2
• Blood pressure elevation may be pain-related but should be monitored after adequate pain control 2
• Documentation should include the time from injury to reduction, as this impacts outcomes 2
• Consider thromboprophylaxis measures due to the high risk of DVT with knee injuries 2

Documentation Pitfalls to Avoid

• Failing to document neurovascular status before and after any manipulation 1
• Omitting the timing of medication administration and reassessment of pain 2
• Not addressing both immediate and long-term management plans 2
• Incomplete documentation of the mechanism of injury, which is crucial for understanding the pattern of ligamentous injury 1
• Failing to document patient and family education regarding the serious nature of the injury 2