He dictates in SOAP format so that might look out of place.
Posted By: Jan on 2008-03-17
In Reply to: i would say Examination and Evaluation needs to be put as a heading. - mt-123
Subject: He dictates in SOAP format so that might look out of place.
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SOAP is a really archiac format, rarely used today
Subject: SOAP is a really archiac format, rarely used today
and occasionally used today but rare.....
soap
Subject: soap
Hey sorry about the wrong board. I'm still a newbie at MT forum but an oldie at transcription. Hey, it's Friday. susan
SOAP
Subject: SOAP
I was referring to the job board for SOAP transcription company. I understood it was a company and not a format. Maybe I'm incorrect.. susan
SOAP
Subject: SOAP
SUBJECTIVE: Chief complaint, etc.
OBJECTIVE: PX
ASSESSMENT: DX
PLAN: self described.
SOAP
Subject: SOAP
I am working on a general practice transcription and I am on the O section talking about blood pressure, weight, heart, respirations, etc., and then it gets to a part right after that, that it sounds like clouds clear and fungus is clear. I know this is not right but I cannot seem to come up with the right words to put in there.
Can anyone help?
soap transcription
Subject: soap transcription
Has anyone heard of SOAP transcription? What are they like to transcribe for?
SOAP notes
Subject: SOAP notes
Was wondering if there are any websites out there that gives sample reports for SOAP notes. Just trying to figure out which is the best way to do it with paragraphs between each heading or all scrunched together. Just want to see what is done more of. I realize it might depend on the clinic, dr, hospital, etc, but just want to get an idea.
Thanks Carla
...and antibacterial soap?? nm
Subject: ...and antibacterial soap?? nm
s
SOAP Report
Subject: SOAP Report
SL "Crenolin" 02-12 are intact.
SOAP report
Subject: SOAP report
SOAP report stands for subjective, objective, assessment and plan.
SOAP Report
Subject: SOAP Report
Subjective, Objective, Assessment, Plan.
SOAP Report
Subject: SOAP Report
Thank you ss. You are so right.
SOAP Report
Subject: SOAP Report
Yes. This is my first time using this forum as a resource and it is great.
SOAP Report
Subject: SOAP Report
SL "Comprhensive 65 plan". Review of Systems by questionnaire is otherwise negative.
SOAP Report
Subject: SOAP Report
Thank you so much ss.
SOAP Report
Subject: SOAP Report
That's it. Comprehensive 65 point Review of Systems. Thank you so much!
SOAP Report
Subject: SOAP Report
She has a chronic non-productive SL "negi" cough.
SOAP Report
Subject: SOAP Report
SL "negi" but I going with your thoughts. Maybe his accent make the word sound funny. Thanks for your help everyone.
SOAP notes
Subject: SOAP notes
transcribing for 7 1/2 week old child. Dictator states fontanels are flat, sound like "contrapendalence" are normal.
format
Subject: format
No.1 PDS or #1 PDS? Which is correct?
Format ?
Subject: Format ?
5/5 strength throughout sensation is intact. So the 5/5 is not at the start of the sentence, how would you reword this phrase?
OB format for G 3, P 1-1-0-2
Subject: OB format for G 3, P 1-1-0-2
Is this how you type that? I havn't heard it transcribed that way before... Thanks!
Format Help
Subject: Format Help
How do you type the name of a book? Italics or quotations? TIA
Format help
Subject: Format help
I have a dictator who constantly repeats words, phrases, entire sentences! Do you transcribe it twice or if she has already stated it, leave it out?
Format ?
Subject: Format ?
Would it be MEDICATIONS: Include
1.
2.
3.
H & P Format
Subject: H & P Format
Just when I think I have it on format - I don't. The following is under PHYSICAL EXAMINATION. What would the subheading be?
Patient walks to the right occasionally. She has trouble getting started because of discomfort. She can walk on heels and toes briefly. However, on a tandem walk she really has difficulty with that. She does not line up her toes easily, loses her balance very easily with that. This is typed as dr. dictated. Suggestions would be appreciated.
could be abbr for Hibiclens soap
Subject: could be abbr for Hibiclens soap
...used a 3-degree ?soap block? ...
Dictation: For this reason, I used a ?soap block? to make a third cut of the tibia, and then this was once again prepared to accept a size 5 tibia baseplate.... Soap block???? Can anyone verify that for me?
s/l *Fizahex* soap? For a wound?
Subject: s/l *Fizahex* soap? For a wound?
Abbreviation Format
Hi... Can someone tell me the correct format for what comes after this med in a dictation: "Zarontin 250 mg 500 500 250 500?" Is this 500 am, 500 mid-am, 250 afternoon, 500 bedtime?
Thanks! 
Abbreviation Format
Subject: Abbreviation Format
Thanks! I thought that would be a mega-dose as well, but that's what she said. I did "slash" them though.
format question
Subject: format question
Do you put immunizations under the Social History section in a report or by themselves? I'm not testing, just confused. The doctor is dictating: "All immunizations are up to date" under Social History. Thanks.
Format question...
Subject: Format question...
Hi, I'm wondering whether AAMT BOS says to type this: "image #31 series 3" or this: "image #31, series 3." Comma or no?
Thank you! :D
Format question
Subject: Format question
This is so small I hate to ask, but everytime I type this it just looks odd no matter what way I type it and would like to know how another MT would type this.
If someone has a dull aching sensation or sharp stabbing sensation would you hiphenate (dull-aching sensation) or slash (dull/aching sensation) or just leave it (dull aching sensation)? Thanks for any input to my "stupid" question. 
I would say cecal and S1-S2 is how I format it...nm
Subject: I would say cecal and S1-S2 is how I format it...nm
s
number format
Subject: number format
When transcribing a very large number, "1 million 120 thousand" is it considered more acceptable to use words or just to stick to numbers?
Format question
Subject: Format question
I was hoping someone might be able to give me the rule for this.....Should departments be capitalized? For instance, "she saw University of Virginia orthopedics" Should orthopedics be capitalized or not? I'm always confused about this:)
format question
Subject: format question
I was taught that if the "orthopedics" came after the name of the place, it should be capitalized (UoV Orthopedics). If not, it wouldn't be capitalized(orthopedic department at UoV). Please correct me if I'm wrong, anyone! :)
Punct? format?
Subject: Punct? format?
REVIEW OF SYSTEMS
He is 6 feet tall and weighs 260 pounds. His weight has been stable. No rashes. No problems with his eyes, ears, nose or mouth. Respiratory: he is positive for a smoker, half pack per day, with a smokers cough. Cardiovascular: has a history of hypertension. No GI/GU problems. Musculoskeletal is stated in the HPI. No neurological or hematological disorders.
Is this how this should be put in paragraph form with the Respiratory and Cardiovascular??
Radiology Format ??
Subject: Radiology Format ??
DUPLEX SCAN OF LEGS
Duplex scan of the arterioles system in the legs was performed and results are as follows:
RIGHT LEG: On the right side,
Is this layout correct? or is it
RIGHT LEG no colon? then drop down a line? Thanks
Format rules in MT
Okay, I am an old gal working mostly ias in-hospital MT (VA, Teaching hospital), but I did also work off and on for MTSOs at home. Now going back a long time, I was always taught that in formatting Problem Lists or Hospital Course by problem list you transcribe it this way. Problem #1 - HYPERTENSION. The patient is taking lisinopril currently..... or if the doc did not say PROBLEM #1, then you transcribed it 1. HYPERTENSION. Blah, blah, blah. When did this change and become wrong? Most of the docs I am now transcribing for one of the major MTSOs now (left the hospital), actually ask that we capitalize the major problem. Is this in the so-called AHDI BOS2?
IMHO, using the capitalization on the problem is much easier to read, than this...
1. Hypertension. The blah, blah, blah..
2. Diabetes mellitus type 2. Uncontrolled. Not compliant.
Any QAers out there can answer this one for this old school nitpicker?
Soap boxes were not made to stand on--sm
Subject: Soap boxes were not made to stand on--sm
please get off or yours.
ESL. Medication s/l soap-uh-MEH-drol 320 daily (sm)
Subject: ESL. Medication s/l soap-uh-MEH-drol 320 daily (sm)
This is in a list of medications. Pt history included in report includes sleeplessness, gastric issues, high blood pressure. Other meds are HCTZ, vm E, Toprol XL, Motrin, and Nexium.
yes, you are talking about the company Soap Transciption Inc.
Subject: yes, you are talking about the company Soap Transciption Inc.
nm
format that to your accts specs (sm)
Subject: format that to your accts specs (sm)
a.m., AM, whatever your acct likes! LOL
Format for multiple problems
Subject: Format for multiple problems
Can someone show me an example of how to type a report that has multiple problems. The doctor does one problem completely, then goes onto the next one.
It doesn't look right typing HISTORY OF PRESENT ILLNESS, PHYSICAL EXAMINATION twice throughout the report.
Thanks
Format & Capitalization (psychiatric)
Subject: Format & Capitalization (psychiatric)
Capitalize verbal, performance, and full-scale? Should I leave the subtest scores in a vertical list arrangement or use a different format?
On this administration of the Wechsler Adult Intelligence Scale-III, Mr. ___ obtained a verbal IQ of 57 (range 53-63), a performance IQ of 64 (range 59-73), and a full-scale IQ of 56 (range 53-61). These scores fall within the mild range of mental deficiency.
The following scatter of subtest scores was obtained:
VERBAL:
Vocabulary: 2
Similarity: 3
Arithmetic: 2
Digit Span: 3
Information: 3
Comprehension: 2
PERFORMANCE:
Picture Completion: 4
Digit Symbol: 4
Block Design: 4
Matrix Reasoning: 5
Picture Arrangement: 4
All the scores above fall within the mentally deficient range and are relatively even.
Go to format/paragraph and you'll see it. nm
Subject: Go to format/paragraph and you'll see it. nm
In MSWord, go to Format, Font,..
Subject: In MSWord, go to Format, Font,..
Effects, place a check mark next to Subscript.
Just a general question on format
Subject: Just a general question on format
I have been using these forums for a while now and I keep seeing people using "nm" and "sm". What does this mean?
nm = no message
sm = see message
Just a guess
Time format in BOS 3rd edition
Can anyone tell me what the specific rules are for time format in the new BOS on pages 337-339. A brief description would be great or u can scan and email it to me too, whichever.
I do intend to buy my own soon but I have to wait till payday. :(
Much appreciated !
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