Office notes versus SOAP:

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

• Office notes versus SOAP: - tml
  • SOAP vs office notes - Patti
  • SOAP is a style. - sm
    • Yikes, should be Plan. nm - Trying to do too much at one time!
  • Usually dictated in the same fashion, but sometimes the SOAP - headings are used, sometimes not. nm Content is sa
    • ...The content stays the same - history, symptoms, - assessment, treatment. NM

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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

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??

Hi,

I am still working in Office 2003 but have been considering Office 2007.  Is anyone using this?  Do you like it?  Do you know if programs like Shorthand, Abacus, and other transcription programs work with it?  Is it possible to have Office 2003 and Office 2007 on the same computer without interfering with the one another??

I am checking into other options for transcription.  Can anyone tell me how to compare all of these types of lines & also payment per word?  I know companies use different scales, so I wondered how they compare.  I have been paid on a 65 character line with spaces, but I may be making a change in the future - don't want to get burned.

Thank you in advance!

I have always charged or been paid by 65 or 60 character lines or per letter or space typed, but have never been paid or charged per gross line.

What is the advantage of this?  If I were to charge 11 cents per 65-character line including spaces, what does this figure out to for an average line rate and how do you do this calculation? 

I'm wondering if it is financially beneficial for me to bill by gross line or to keep it the way I have it.  I do know some accounts will only pay per 65-character line, as this was the deal my first own account I recently acquired.  They were adamant on a 65-character line, but didn't specify with or without spaces and I personally would never not charge for spaces.

Thanks for explaining this.  I appreciate it and hope everyone has a speedy day.

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.