Do you put "License xxxxx" on a SOAP note for signature title?

I am typing up a SOAP note template for a new PT.  He gave me his credentials, plus his "number," which is his license number for his signature title.  He did not say to put License in front of the number, but I think it looks funny without it. Has anyone ever done this before?  Is it appropriate to put the word "License" before the number?  He is away from the office, otherwise I would ask him myself.   

Thank you!  

• Do you put "License xxxxx" on a SOAP note for signature title? - MTToo
  • in my experience...sm - ks
  • I would think you would have to ask him. - jd

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For those of you who transcribe SOAP notes, do you capitalize each word in the diagnosis?  I have seen it both ways, and I was not sure if there is a rule to this. 

DX:  Low Back Pain. 

DX:  Low back pain.

Thank you!

First of all, I am sorry for your loss.

Second, how can he even say anything is owed since you have the title in your hand? 

Hope it all works out for the best.

I own a small home based medical transcription business and have been asked by prospective new clients about electronic signature capabilities.  Can anyone recommend a company or any advice regarding my document management needs.  I currently have physician offices set up digitally without any electronic signature capability at all.

Thanks

Hi,

Does anyone know about offernig E-Signature to a client? Is there a way to do it easily, on your own -- I mean, instead of signing up with a big company like Vianeta or Bayscribe to handle all of the reports you type and want to send to a client.

Or... If that's the only way to go - through a big company - are there any big companies that are economical if you just have 1-2 doctor clients?  I know some of those companies charge like $5,000 as a set up fee.  Thank you.

Dave

 I mean, I'm sure you can do it

Need to set up nurse practitioner dictator with Doc signature block, think I know how it should be set up but it's been awhile.  Any current examples or preferences of how anyone likes to do this?    Thanks. 

Yes that is correct they are chart or clinical notes.  The dentist that I used to work for liked the charts written up in that fashion.

S- subjective

O- objective

A- assessment

P- plan

I may sound dumb, but what is a SOAP note??

I have my my own account of three OB-GYNs that use a SOAP sheet type heading on a regular piece of paper. It takes up about 2.5" on the top of the first page of each patient note. It is paper that is purchased from a printing company and they write in the patient's name, vitals, LMP, type of contraception, etc. in the appropriate areas. I have my margins set so I start typing under this info. The problem I have had is these sheets will jam up in any of the three printers I have and I just bought a new all-in-one printer and these sheets will actually get so stuck I have to tear them out of my printer! I know it is because they have been handled, written on, sometimes have corners folded, etc. I normally have a second page I print and sometimes even a third, and I print all the notes at one time or it would take me forever to print out their transcription as I normally have 30-40 pages from each doc! I even made sure the paper I purchased for second, third pages is the same weight as this SOAP heading sheet and it makes no difference. It does not jam with every first page/header page, but it does it on average at least three times while I am printing out one doc's work. This wastes a lot of my time, is frustrating, and I feel it is going to ruin my printer/roller bar with it jamming so badly.

When I spoke with the OM, she said they would quit sending these SOAP sheets with the info on them and then they would just add them to the patient's chart as the first page after I return the transcription. However, I just received a message when I returned home that the docs are not happy with this and do not want it done this way.

When I met with the OM, she said they can change this pre-printed "form" to a half page (which will save them money). I am not exactly sure why they do not like the way things have been changed other than this pertinent info is no longer directly on that first page of the patient's note.

Does anyone have ANY suggestions as to what I could do that they might agree to? I know I had mentioned to the OM when I met with her (to discuss going digital) that perhaps they could use the same form on a half page or even smaller as a label to adhere to the patient note and she said "no way"! They will NOT use adhesive anything. I need to resolve this problem TODAY so sure would appreciate some suggestions/feedback.

TIA.

Some of my docs use the SOAP  -see below, all broken down into these paragrahs with headings.

S: (subjective)

O: (objective/physical)

A: (assessment)

P: (plan)

Others, my surgical oncology docs, just dictate and I put them in paragraph form and no headings.   Also I have one that does the S and O and then puts his Assesment and Plan in one paragraph.  

Hope that helps.  Patti

Could someone explain the difference between an office note and a SOAP note when doing transcribing for a specialty doctor. Thanks.

or is it common to transcribe headings within a SOAP report? For example, a SOAP report with a PE section?

Thanks in advance!