Maybe you put that you do SOAP notes and HR

• update on my job hunt - CS
  • common - Rene
  • simply ask HR if it's common practice to hire for a department - - other than the one applied for. n/m
  • Maybe you put that you do SOAP notes and HR - got confused? (collective groan...). nm
  • benefits? - debbb
    • benefits - CS
  • Why not think about it this way? - sm
    • That's a little bit of a harsh assessment, IMO. - tnmt
      • Exactly - normally we overqualify
    • I agree that is what probably happened - mdlfcrs
  • often HR will share your ap - with all departments in the hospital
    • experience - CS
      • This would put me over the edge - Anon
  • Hope you called HR back. (nm) - lynn
  • WHAT?? - homt
    • yes, i am for real-sm - CS

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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??

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.

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.

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!

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

Thanks in advance!

Promoting her little dream of a soap opera with press conferences with her super glossy eyeshadow and false eyelashes.  Sweet.  How many opportunities does Mrs. Twitty get to get all this attention?  Might as well milk it.

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!  

Don't worry.  It has been my experience being a Transcriptionist for a huge hospital that I loved the ER notes the most.  They are really pretty much abbreviated H&P's and are sometimes the most interesting reports of all.  Not nearly as difficult as some surgeries or discharges notes can be.  Simple and brief and sometimes a really good story.

I do two internal medicine Docs, SOAP notes only and minor procedures and love it  I also did other specialities, but all that was lost to outsourcing to INDIA!

I love doing OP notes. They are so interesting. Anyway there is a website that I use now and then and it is

www.mt911.com it also has samples.com on it and has alot of different samples.

Also a good reference book is The surgical word book by Saunders.

Hope this helps.