Question regarding SOAP note...
Posted By: Help... on 2008-02-06
In Reply to:
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!
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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!
What's a SOAP?
NM
SOAP
It's an acronym for SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN. I recall back in the late 1970s when the hospital at which I was working as an RN began requiring us to write all of our notes in SOAP format. What a pain!
SOAP
It depends what format the client wants: I had an account where the only double spaces were after the heading (Name and DOB) and at the very end before the name of the dictating physician.
The body of the note was all single spaced, no double space between S, O, A and P.
PT SOAP work
I am an MTSO and I would be interested in talking to you further. Please email me.
Well that's quite a soap opera . . .
I used to live in Southern California and your description reminded me of someone I used to know, especially about interrogating the waiter. Loved that you called her the Bee. You sound very down to earth and she is not. As for the clothes - everything has a price doesn't it. She's probably shocked that those clothes didn't mean that much to you and you'd do anything to keep on receiving them. Good for you.
SOAP is a style.
Subjective, Objective, Assessment, Prognosis. Some offices like to their office notes typed in this kind of format, others don't.
Maybe you put that you do SOAP notes and HR
nm
What are SOAP notes?
nm
soap notes
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
SOAP Notes
I may sound dumb, but what is a SOAP note??
I used to wath soap operas.....
Now I just come to this board every day, lol.
HELP with SOAP sheet issue please!
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.
The soap under the sheet really works.
My husband thought I was crazy but it did work.
Just like an H&P, but sometimes without headings, sometimes use the SOAP designations. nm
s
SOAP OPERA SCRIPTS
Does anybody know who types scripts for soaps or other TV shows? I've been an MT for 30 years and am beyond burned out with medical reports. Figure I could use a change and thought I'd really enjoy something like this. Thanks!
Not so silly. I still don't know what SOAP means.
nm
I think SOAP Transcription does only ER/ED files. nm
s
Usually dictated in the same fashion, but sometimes the SOAP
s
SOAP vs office notes
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
I take mine apart before it gets the soap and water bath. nm
//
Dawn dish soap for fleas
I had this problem before with some kittens. Soak the pup down and scrub it up with dawn dish soap. Apparently the fleas get caught in the "bubbles" and suffocate. Leave this on the puppy for about a 1/2 hour to an hour then rinse. Keep in mind that this does work BUT dry skin occurs.
Try Murphy's Oil/Soap - toothpaste is abrasive
/
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.
Is SOAP format always in paragraph form? *sm*
or is it common to transcribe headings within a SOAP report? For example, a SOAP report with a PE section?
Thanks in advance!
I think you're in the wrong profession - write soap operas!!
nm
Why I believe Mrs. Twitty is writing the soap opera and starring in it too!
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 use a mild, nondrying, unscented facial soap and
Oil of Old Lady for sensitive skin.
J&J baby soap at bedtime with a small amount of
coral calcium and glucosamine chondrontin with MSM daily with Omega-3 fatty acids every other day. Hair, nails and skin are better than ever at age 45.
SOAP's pay is higher even in the trainee/newbie stage. nm
s
oh my gosh, would you, yourself, bathe in DAWN dish soap - ouch!
no, no, no, no, no, no, no.
Vaseline works too and to rinse out use Dawn dish soap.nm
x
oh yeah, forgot that one. Worse than a soap opera. Geez! nm.
.
You're correct. Thanks! I found 2 on the SOAP transcription site
s
Pros and cons on SOAP transcription versus MediVoxx? nm
s
I am looking for samples of podiatry notes typed in SOAP format. sm
I have a potential client who would like to see some samples typed up and then let him know how much that report would cost. I charge by the line, and this is something that he is not familar with. Would appreciate about 3 or 4 reports, hopefully one of them being lengthy. TIA
My favorite moment on a soap was years ago when Hope was marrying someone else and Bo came up riding
on his motorcycle to break up the wedding and take her away. I always thought that was the most romantic thing in the world! My favorite was the Christmas episodes when Mrs. Horton would put up the Christmas tree bulbs of all of the family members and it was basically like reliving the old episodes.
NEW CONTRIBUTION! Candles & Soap courtesy of Incredible Soy. Click on Santa's
/
Turn off the soap opera network and get a clue, drama queen!
That's what a lot of you around here do, find drama in otherwise innocent posts. Get a life, get back to work. And above all else, you call me a hypocrite and yet you sit in judgment of me.
Thanks for your note. SM
I think this problem must be specific to my particular account. I have tried all the things we were told, clearing, entering new names to try, etc. Thanks again.
Note to MQ: What would be
retired MTs in your workflow room and being TC's.>?
I am so tired of dealing with haughty people who don't have a clue
why I need something or what I do - and on top of them coping an
attitude with me because I get exasperated with their inability
to do their job which is make the work flow.
If MQ had people hired in their work flow areas who had worked inside
the world of transcription and knew where it goes in a hospital,
what to look at on the screens of the machines in the work flow rooms,
etc etc we wouldn't be getting hysterical messages all the time about
not meeting turn around times.
But no! they want to hire first-time jobbers to be in control of the lives
of people who have been in the business usually upwards of 15 years
in order to even do this MT job at home with no help or assistance -
and then make us put up with them and at the same time try to make a living.
I don't want a doctor operating me who has never been inside a hospital, and I
am sick to death of dealing with people in a transcription company
who has never been inside a hospital and followed a REPORT around.
They need to see WHY A REPORT is done - HOW IT IS DONE
They need to go to dictate stations - they need to go in a medical records
area and look at charts - go inside an OR - and into the ICU
they need to see how the world of medicine is and how it operates.
Only then will they understand TATs, reports, and why things are done as they
are or at least why people want them done a certain way.
Like if I keep getting dictations with LOUD BUZZING - i don't want to keep getting
LOUD BUZZING - I want to let the hospital know there is probably a bad phone
instrument - and if this work flow person sees where dictation is done he will
understand it wouldn't take much to MAKE THE BUZZING STOP - and not get
pissy with me because I'd like to talk to somebody about LOUD BUZZING ON
REPORTS. - It's not rocket science - just need to let somebody know.
I know this isn't a note, but
maybe this will be of some help, I'm still searching for a note.
Breast-Related Medical Terms
GLOSSARY OF MEDICAL TERMS
Areola The pigmented or darker colored area of skin surrounding the nipple of the breast.
Asymmetry A lack of proportion of shape, size and position on opposite sides of the body.
Autoimmune Disease A disease in which the body mounts an "attack," disease response to its own tissues or cell types. Normally, the body's immune mechanism is able to distinguish clearly between what is a normal substance and what is foreign. In autoimmune diseases, this system becomes defective and produces antibodies against normal parts of the body, causing tissue injury. Certain diseases such as rheumatoid arthritis and scleroderma are considered to be autoimmune diseases.
Axillary Pertaining to the armpit area.
Bilateral Pertaining to both the left and right breast.
Biopsy Removal and examination of sample tissue for diagnosis.
Breast Augmentation Enlargement of the breast by surgical implantation of a breast implant or patient's own tissue.
Breast Reconstruction Surgical restoration of natural breast contour and mass following mastectomy, trauma or injury.
Capsular Contracture Tightening of the tissue surrounding a breast implant which results in a firmer breast.
Capsulectomy Surgical removal of the entire capsule surrounding a breast implant.
Capsulotomy Closed Capsulotomy: Compression on the outside of the breast to break the capsule and relieve contracture.
Open Capsulotomy: Surgically cutting or removing part of the capsule through an incision.
Carcinoma Invasive malignant tumor.
Congenita Anomaly Abnormality existing at birth.
Connective Tissue Disease(CTD) A disease or group of diseases affecting connective tissue. The cause of these diseases is unknown. The diseases are grouped together on the basis of clinical signs, symptoms, and laboratory abnormalities.
Deflation/Rupture Refers to loss of saline from a saline-filled breast implant due to a tear or cut in the implant shell or possibly a valve leak.
Displacement Shifting in the original position.
Epidemiological Pertaining to the cause, distribution and control of disease in populations.
Extrusion A breast implant or tissue Expander being pressed out of the body.
Fibrous Tissue Tissue resembling fibers.
Hematoma A swelling or mass of blood (usually clotted) confined to an organ, tissue, or space and caused by a break in a blood vessel.
Immune Response The reaction of the body to substances that are foreign or are interpreted as being foreign.
Inframammary Below the breast.
Inframammary Fold The crease at the base of the breast and the chest wall.
Inframammary Incision A surgical incision at the inframammary fold
In-Patient Surgery Surgery performed in a hospital requiring an overnight stay
Latissimus Dorsi Two triangular muscles running from the spinal column to the shoulder.
Mammography Use of radiography (X-rays) of the breast to detect breast cancer. Recommended as a screening technique for early detection of breast cancer.
Mastectomy Surgical removal of the breast.
Subcutaneous Mastectomy: Removal of breast tissue, preserving the skin and nipple.
Partial Mastectomy: Removal of primary tumor and a wide margin of tissue, may include the overlying skin and the muscle fibrous tissue (fascia) underlying the tumor.
Total (Simple) Mastectomy: Removal of breast tissue and the nipple; sometimes accompanied by armpit (axillary) node dissection.
Modified Radical Mastectomy: Removal of breast tissue, nipple, and fascia of chest (pectoralis) muscle with axillary node dissection.
Mastopexy Plastic surgery to move sagging (ptotic) breasts into a more elevated position.
Necrosis Death of tissue. May be caused by insufficient blood supply, trauma, radiation, chemical agents or infectious disease.
Oncologist A specialist in the branch of medicine dealing with the study and treatment of tumors.
Out-Patient Surgery Surgery performed in a hospital or surgery center not requiring an overnight stay.
Mammaplasty Plastic surgery of the breast.
Mammary Pertaining to the breast.
Palpate/Palpability To feel with the hand.
Pectoralis The major muscle of the chest.
Plastic Surgery Surgery intended to improve, restore, repair, or reconstruct portions of the body following trauma, injury or illness.
Prosthesis An artificial device used to replace or represent a body part.
Ptosis Sagging of the breast usually due to normal aging, pregnancy or weight loss.
Rectus Abdominus Major abdominal (stomach) muscle.
Saline A solution of sodium chloride (salt) and water.
Seroma Localized collection of serum, the watery portion of blood, that resembles a tumor.
Serratus Muscle located beneath the chest's pectoralis major and minor muscles and the rib cage.
Silicone Elastomer A type of silicone that has elastic properties similar to rubber.
Subglandular Placement Placement of the breast implant behind the skin and mammary gland, but on top of the chest (pectoralis) muscle. Also called prepectoral or retromammary placement.
Submuscular Placement Placement of the breast implant under the chest (pectoralis) muscle, or under the pectoralis and serratus muscles. Also called retropectoral or subpectoral placement.
Surgical Incision Cut made in tissue for surgical purposes.
Transaxillary Incision Incision across the long axis of the armpit (axilla).
Umbilical Relating to the navel.
Unilateral Affecting only left or right breast.
Anyway, sorry, on a more serious note...
as regards your problem: Do you have Ad-Aware and SpyBot and have you run those? If you have run those and are still not finding anything, you might want to try a trial of this program I just downloaded myself and seems to have gotten rid of this darned WinFix (Virtumond?) pop-up problem I've been having recently that my Ad-Aware and Spybot couldn't seem to take care of. Dang, I might actually buy this one! But anyway, you can use it for 2 weeks, I think it is, for free (see link below).
Just a note: There are two MTs that I will not SM
use to this day - 15 years down the road - because they did this. They will never get a recommendation from me and they will never sub for me.
You leave a long trail when you do something like this.
on another note
I know a lot of people believe as you do, but in my family I have seen lots of evidence to contradict this theory.
I don't condemn anyone who overdrinks, but I think we spend too much time in our culture blaming genetics and other people - mostly our parents - for our own poor choices and bad behaviors.
Bottom line is, the alcohol does not force itself into anyone's mouth and neither do the drugs. To me, drugs include not just the street drugs, but the legally obtained prescription drugs that so many people rely on to get them through the day (do not flame me about arthritis meds, etc. taken for legitimate conditions).
P.S. and it's an OP note!
nm
On that same note...
I wonder if any of you report errors you notice in other reports to the QA at your office. I have seen some doozies, but I admit I have been remiss. I just wanted to know what the rest of you do, even if the report is old.
sorry -- BAD day. (no note)
.
NOTE,,,,,,,,,,,,,,,nm
nm
perhaps you could drop your TC a note...sm
just to say hi, and welcome. She/he has many, many more people to get in touch with than you do, so why not make the first move? I'm not at all trying to be ugly, please don't take it that way, it's just, why not just send a message saying hi, and introducing yourself? Just a thought! Good luck with whatever you choose to do!!! 
perhaps you could drop your TC a note...
I guess you mean Transcription Coordinator -- what I called my new supervisor. I hear you, but I really don't see that as my responsiblity. MQ is so chaotic, I always get the impression they'd greatly prefer not to be bothered. I'm kinda way past that point with that. Thanks for the welcome anyhow.
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