Not op notes but

• Sample OP NOTE specifically ORIF - Judy
  • Stedman's Orthopedic Words - Joy
  • Not op notes but - sm
  • I believe MT Desk has samples. - n/m

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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.

Any good sites for OP notes?

thanks Lori

Does anybody have any tips on the best places to specialize in op notes?   I need a place where I can do heavy volume ops -- not interested in basic 4 stuff.

Thanks.

Was wondering if anyone could help me out.  I need to see some example of different ways to set up chart notes.  If anyone knows of a place on the net i can view these of would send me some blanked out that would be great!!!!!

Thanks,

Jackie

would be a good place to start, either working as an IC/employee for a national or getting your own accounts.

Good luck!

I love doing op notes. They are very difficult though and i do recommend that you go into them slowly if at all possible. I was doing strictly clinic notes when I came to work here, but lost a girl that did the Op notes and we decided to send our clinic notes out to someone else and I started doing OP notes and other types of dictations. They are my fav.

Mostly clinic notes from my experience:

S - subjective

O - objective

A - assessment

P - plan

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??

Do you mean that they are written notes or are they on a dictaphone system??  I am just wondering why you would need someone close by?  bj

I have that problem once in a while and my doc and I got into an argument about it once. I knew he didn't dictate the notes, but he kept telling me he puts a check mark on the notes he does dictate. 

I've been with this doc since 1995 and I have a phone in system, so if he dictates them, they're transcribed. If he doesn't dictate them, then he didn't do them.

Well, for how busy he is, if he put the check mark on the note PRIOR to dictating, then gets called away for a patient or starts to fall asleep while dictating (which he has done already), it could very easily be overlooked. What aggravates me is that he makes me type Re-dictation on any notes he says he did before but didn't.

Also, I have found that since the last secretary left, there aren't as many "missing notes" as before. Hm-m-m-m. That tells me something. I can understand if I put a blank for the patient name (no list to follow and if it's a new patient or can't understand Speedy Gonzalez, then those notes could very well be thrown away if they can't verify the patient.

I don't print the notes or hand deliver them anymore. We use PCAnywhere, and the notes are in one file with the dates of the notes dictated, which I transfer directly to his computer, so they print them out on their end. I have the notes and so do they, so if they are missing a note, all they have to do is check their files to see if that note is there. If not, then he didn't do it.  End of argument.

This has worked out great for me, but for you, well, I'd think twice about keeping a job with that much aggravation. Find another account.

I have been having an awful time getting straight with my company whether to use parenthesis for (Please see nursing notes.) etc.  I get corrected back and forth whether the word "see" has to be involved or if "per" is enough or even just (Nursing notes.) because it is implied to look there.  (No matter how I do it, eventually someone says it should be done the other way.)

To top it off, now someone else has totally not answered that part of the question but has said it has to be more specific, such as (See nursing notes dated 02/12/2008.)  That, see nursing notes is too vague, so not to used (  ).  I switched to doing it that way, and got corrected again!!

I end up feeling like a pain in the butt because I keep trying to get an answer, but I get so stressed out by constantly being told by a different QA person to do it a different way.

Anyone else with an issue like this?  And, how do you all handle this particular issue? 

When I was told by QA to do it one way and the next QA a different way, I copied the e-mail and sent it to the other QA and the QA manager, and asked them point blank, which way is correct.  So from then on they asked everyone to save their messages from QA to make sure everyone was working on the same page so to speak, and that stopped that, because they were told do it this way.   Because, found out different QA people have been taught one way and the next QA person the other.  They all have to get on the same page, choose one way or the other and not stress anyone out.  Hope this will stop for you.