Subjective, Objective, Assessment, Plan=SOAP..

• soap transcription - susan
  • ah, if you had only crossed the t in Transcription *L* - easy to do; most MDs trend away from SOAP
  • Subjective, Objective, Assessment, Plan=SOAP.. - easy to do; most MDs trend away from SOAP
  • Wrong board, but - clhmt
    • you totally misunderstood OP's query....*LOL* - easy to do; most MDs trend away from SOAP
      • forgive me, it was ME who totally misunderstood! - easy to do; most MDs trend away from SOAP
        • No problem! With all the answers, we've covered all the bases! - clhmt
    • soap - susan
  • You posted on wrong board. This is the word board. nm - ae
  • You are talking about the company, correct? - uhhhhhh
    • Duh on me. Sorry I misunderstood. nm - Txczech
  • Sorry. Here is an example in this link. - Txczech
  • First time I heard that I was WHAT?? but sm - Txczech
    • SOAP - susan
      • yes, you are talking about the company Soap Transciption Inc. - no message
  • SOAP - SM
    • nice to see I wasn't the only one who...sm - easy to do; most MDs trend away from SOAP

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1.      Erythrocytosis – the patient did have a hemoglobin of 17 on blood work one year ago.  I asked him to repeat it, but he forgot.  We will recheck his CBC with NORRIS REPREEDIN level today and work this up accordingly.  He is not symptomatic.

I keep listening over and over to this, and this is all I can make out.  Any clue what he might be referring to??? TIA

If the doctor says assessment and plan together, do I put the header together? I am confused because when he gives the assessment he numbers them 1) 2) then when he gives the plan he numbers them as well but does not say plan any help?

ASSESSMENT:

1. Bilaterally arm numbness.
   
2. Nausea.
   
3. Health maintenance recommendations.

PLAN:

1. Patient’s critical examination was hyperreflexia suspicious for possible cervical lesion.  She will be referred for MRI with cervical spine.  Patient may need EMG to further access her numbness.
   
2. Patient will be tried on Nexium, although she does not have any overt symptoms of heartburn.  She does have chronic nausea and this may be a sign of stomach reflux.  She will be tried on Nexium 40 mg one q.d.  Other diagnostic possibilities include slow gastric emptying. The patient does not eat breakfast or lunch and has her largest meal at about 8:00 at night.  We discussed the need to consume breakfast and ideally eat 3-5 meals per day, smaller meals to encourage her metabolism.  ___ problem health maintenance and in regards to increase her exercise and changing her diet.  Patient will be referred to OB/GYN for Pap and pelvic and also will be referred for a screening mammogram.  When she follows up to see me we will discuss potential options for colon screening.  Patient is to follow-up with me in approximately 1 month time. 

The wound has been cleaned by the nurse, and it looks very good.  s/l Pride flesh is starting to form.

TIA for any suggestions!

does this make sense to anyone

GU and rectum s/l farum are rectal sphincter muscle tone

findings, when doc says, for instance, "In general, the patient is..." you are putting that under the "general" subheading, so you don't need to repeat the "in general" part - meaning it would just be GENERAL:  The patient is....

same with the skin exam that you have there - if doc is saying "skin is warm and dry," and you are putting it under the "skin" subheading, it should just be "SKIN:  Warm and dry" ...and so on.

also, in the HEENT section, it should be "sclerae" and "conjunctivae" - doc is referring to the plural form here.

Does that make sense?  This is the way it's usually done, but you'll need to follow the instructions you've been given, of course.

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

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

ASSESSMENT: Family history of AAA.  Will proceed with -- s/l "root" ----- to evaluate. 

Anyone have any idea what this is?? I'm drawing a blank.

TY!!

Hypertension with  s/l "realciaporosis"...??

Any ideas??

TIA

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?

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Doc states CABG and mitral valve repair.  He clearly states this together.  Can this be listed as one assessment?  Or should mitral valve repair be next number??

Is uncompelling a word?

Or is it noncompelling?

Thanks!