SOAP is a style.

• 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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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??

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.

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

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!

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

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!  

I've been working at home as an employee for over a year - using a style that was provided by the employer - now I have received a message that the style is switching to AAMT styleguide which is different from what I have been doing.  Has this happened to anyone else?  Just wondering why anyone would change midstream.  This is an old account and I don't know if there were complaints or if the style is being dictated by the company or the physicians - who don't really use any kind of style - we just try to make it uniform. 

I've been typing for the same clinic for the past seven years.  Our policy is to make all sentenses as complete as possible to make for better reading.  

I'm going to test tomorrow for a part-time job with another company.  My question is, do I type it like the doctor says it or do i make complete sentenses?

Example:

Doc says "patient has CLL."

I usually would type "The patient has chronic lymphocytic leukemia."

is a pollen allergy treated the same as a drug allergy, caps and bold?

The cardiologists I have worked with over the years preferred Roman Numerals for murmurs, however, all that changed when The Book of Style came out indicating to record murmurs with numbers not Roman Numerals.  I even had a few cardiologists state, put the murmur in Roman Numerals.