Lots of Detail for Lots of Help!
Posted By: Corrie on 2009-05-01
In Reply to: How about normocytic? - Guessing here
Subject: Lots of Detail for Lots of Help!
Okay, I'm transcribing a SOAP note and this word that I'm trying to figure out is under the ASSESSMENT AND PLAN part. She says the word three times and I am now thinking she is saying something like "number next or number next is." What do you think?
(Normonaxis) Anemia may be caused from a recent epistaxis. He will start an iron pill daily over the counter called Fergon. Next visit we will check a hemoglobin, iron studies. (Normonax) He was in for right shoulder pain in the past. This was resolved. (Normonax) Recent qualm was treated with doxycycline.
Also, I was told to transcribe this using a straight SOAP format, but the doctor dictates things like "Review of Systems" and "Exam." I didn't think those headings or subheadings were in a SOAP format. She never dictates "Subjective" or "Objective," only "Assessment And Plan" as one heading towards the end of the report. Any advice?
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d
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