SOAP Report

• SOAP Report - msjomoe
  • Cranial nerves II-XII are intact? - ss
    • SOAP Report - msjomoe
      • Glad to help. ss - ss
    • SOAP Report - msjomoe
      • Thanks on the info. Never heard of SOAP report. Always learn something new. nm - ss
        • SOAP is a really archiac format, rarely used today - SOAP used back in the 50s-60s....sm
          • Rare? Every clinic I do uses them. nm - .
            • some clinics still might, hospitals rarely though - I do hospital medical records...and private..sm
      • Was your sounds like the cranial nerves? ss - ss
        • SOAP Report - msjomoe
          • Yes, you will get a lot of help here. nm - ss
    • SOAP report - MTMI

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She has a chronic non-productive SL "negi" cough.

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?

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

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?

and occasionally used today but rare.....

the patient had an implanted pacemaker which is not eluded to here.  Just a note, adenosine is not capitalized except to start a sentence.

Maybe you will hear something back.

d~

"CPK and _______ were negative"  s/l intraconals??

Still on the pulmonologist's report...

What kind of surgery is it? If he used "lap" laparotomy pads may be the second one. They usually say sponge, needle and instrument counts. Will keep thinking on this one. Type of surgery would help.

Vocal cord lesion biopsy -

Peripheral -s/l orb or oral- sinuses were intubated to their apices and were normal.

Specimen was sent -s/l informal- and for pathology.

TIA!

OP report, lumbar spine

Next, fluoroscopy was used to place new screws at the L2-3 segment.  Starting points were identified at the confluence of the midpoint of the transverse process, the **manloid** process, and the pars interarticularis

He really mumbles through this part, so I am just not sure, but I have not heard this term used before. Thanks!

FINDINGS:  Epidurogram revealed normal (s/l-cephaloquadet-) contrast flow outlining the right L5 nerve root sleeve in the epidural space with good flow achieved medial to the right L5 pedicle.  The patient did experience some concordant L5 symptoms on the right side during the injection.  Vital signs remained stable throughout. 

Patient was premedicated with intravenous s/l Benadryl. 

Would that be right?

I never do op notes!  The sentence reads:

The S/L RAFFAY between the anterior and middle deltoids was then opened.  TIA!

The patient has focal severe slowing primarily in sensory fibers in the right upper extremity, on multiple restimulation unable to elicit a response to both s/l "Palmar 8" studies. 

I can't find this anywhere.  Anybody have any ideas?  Thanks!

The patient has a 4 mm calcification on the pelvis on the right which may represent a s/l flevolith, thus a right ureteral calculus could not be entirely occluded.