SOAP Notes
Posted By: amylou on 2008-01-16
In Reply to:
I may sound dumb, but what is a SOAP note??
Complete Discussion Below:  marks the location of current message within thread
The messages you are viewing
are archived/old.
To view latest messages and participate in discussions, select
the boards given in left menu
Other related messages found in our database
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 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
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.
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
And you'll almost never get just Op notes. Probably get mixed acute care - op notes, discharge su
s
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.
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
Question regarding SOAP note...
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!
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
/
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
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!
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.
ER notes
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.
OP NOTES
I just started doing op notes at the hospital I work in and it is hard as there are so many different instruments they use that I have never even heard of. I use a surgical word book and Google a lot. That's about it.
To me, O.R. notes
 get really boring. I prefer discharges - just my personal opinion. Plus once I get used to them, I can go really fast.
Doc notes
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!
op notes
Operative notes. Perhaps as far a leap from clinic work as is possible. Not something for you to jump into with no experience.
Not op notes but
This site has brand names of surgical instruments. You can choose by speciality and manufacturer also.
http://ptiresource.50megs.com/about.html
Even for op notes? sm
I can see where being paid this way would have its advantages when doing DS and work types where there is a lot of paper shuffling, looking for values, etc., but I am concerned about op notes where the dictation is speedier.
OP notes
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.
OP notes
I only type OPs. I have done it for 8+years and LOVE IT. Its a niche that is hard for companies to fill, it seems. I would say it would be a great move on your part. Good luck!
Op notes
At my current company, op notes are paid at 9 cents a line for over a year experience. At my previous company, op notes were paid the same as any other type of report; cpl was based on difficulty of the account and ranged from 7.5 to 10 cpl, with op notes being paid the same as other basic 4 reports.
OP notes
If you already work for a service, maybe they have OP accounts. I would tell them you would like to learn. Ask if they could assign you a few each day and have them go to QA for feedback.
I would also buy a few surgical reference books. I feel the books are much easier to use than Google because so many instruments, brand names, etc, sound alike.
Good luck. I love my OP accounts.
|
