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Just like an H&P, but sometimes without headings, sometimes use the SOAP designations. nm

Posted By: wanderer on 2006-04-03
In Reply to: Chart Notes - Jackie

s


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  • Chart Notes - Jackie
    • Just like an H&P, but sometimes without headings, sometimes use the SOAP designations. nm - wanderer

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Other related messages found in our database

how often do you see ANY degree designations on credits? nm
x
headings
control B.
Headings sm
Gosh, in the old days, I would have resorted to just putting this all under HEENT if you could. It really doesn't belong under ENT, everyone knows the eye does not belong here. Who knows anymore?
headings
If your company uses templates where headings such as HPI and PE are already there, you may not get credit for those character lines. I had this issue at a former company so that may be part of it. Just a thought!
Autocorrect Bolded Headings
I spent quite a bit of time yesterday entering bolded headings into Autocorrect using the Formatted Text button rather than the Plain Text button.  I go into WORD today and all my Formatted bolded entries are gone.  What did I do wrong or what can I do to make sure these entries are saved?  Would appreciate any help.  Thank you.
HEADERS....as in what? The things like HISTORY AND PHYSICAL headings?

or the heading at the top of the page that we don't type?


and do you find it a little offputting that they can't put in writing that they pay for spaces?  it makes me think all is not kosher. 


 


 


 


Enumerated lists and underlining for headings in exam
I was wondering if any of you can help me, and possibly even give me a reference, regarding enumerated lists, specifially in an exam. Example is:

1. General Comments:

2. Response to Medication:

3. Medication Compliance:

Etc.

What I am wondering is the clinic likes the section to be underscored (i.e., General Comments); however, should the underscore include the number or just the words titling that section? I have been doing the latter; however, the person I share the account with underlines both the number and title.

Thanks for your help.

Linda
I see them all, too. Some people seem to be missing headings from the blue bar on the left. nm
s
Shorthand users - How can I keep headings bolded in PE. I want to make
a shortcut for parts of the PE and headings need to be bolded.  I cut and copied what I want into SH but when it pulls up they are not bold.  TYIA.
Basically formatting, how to type the headings, numbering, etc...sm
Are headings capitalized or followed with a colon?

ex.
HISTORY OF THE PRESENT ILLNESS:

Is it p.r.n., prn, h.s. or bedtime?

Just your basic formatting and styles. I may just download the ebook. Thanks!
It's something in Word, not ExText. Check your Format/Insert/Tools headings. nm
s
What's a SOAP?
NM
SOAP
It's an acronym for SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN.  I recall back in the late 1970s when the hospital at which I was working as an RN began requiring us to write all of our notes in SOAP format.  What a pain!
SOAP
It depends what format the client wants: I had an account where the only double spaces were after the heading (Name and DOB) and at the very end before the name of the dictating physician.
The body of the note was all single spaced, no double space between S, O, A and P.
PT SOAP work
I am an MTSO and I would be interested in talking to you further. Please email me.
Well that's quite a soap opera . . .
I used to live in Southern California and your description reminded me of someone I used to know, especially about interrogating the waiter. Loved that you called her the Bee. You sound very down to earth and she is not. As for the clothes - everything has a price doesn't it. She's probably shocked that those clothes didn't mean that much to you and you'd do anything to keep on receiving them. Good for you.
SOAP is a style.
Subjective, Objective, Assessment, Prognosis. Some offices like to their office notes typed in this kind of format, others don't.
Maybe you put that you do SOAP notes and HR
nm
What are SOAP notes?
nm
soap notes

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


SOAP Notes

I may sound dumb, but what is a SOAP note??


I used to wath soap operas.....
Now I just come to this board every day, lol.
HELP with SOAP sheet issue please!

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.


The soap under the sheet really works.
My husband thought I was crazy but it did work.
SOAP OPERA SCRIPTS
Does anybody know who types scripts for soaps or other TV shows?  I've been an MT for 30 years and am beyond burned out with medical reports.  Figure I could use a change and thought I'd really enjoy something like this.  Thanks!
Not so silly. I still don't know what SOAP means.
nm
I think SOAP Transcription does only ER/ED files. nm
s
Usually dictated in the same fashion, but sometimes the SOAP
s
SOAP vs office notes

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


Question regarding SOAP note...

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!


 


I take mine apart before it gets the soap and water bath. nm
//
Dawn dish soap for fleas
I had this problem before with some kittens. Soak the pup down and scrub it up with dawn dish soap. Apparently the fleas get caught in the "bubbles" and suffocate. Leave this on the puppy for about a 1/2 hour to an hour then rinse. Keep in mind that this does work BUT dry skin occurs.
Try Murphy's Oil/Soap - toothpaste is abrasive
/
Office notes versus SOAP:

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


Is SOAP format always in paragraph form? *sm*

or is it common to transcribe headings within a SOAP report? For example, a SOAP report with a PE section?


Thanks in advance!


I think you're in the wrong profession - write soap operas!!
nm
Why I believe Mrs. Twitty is writing the soap opera and starring in it too!

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 use a mild, nondrying, unscented facial soap and
Oil of Old Lady for sensitive skin.
J&J baby soap at bedtime with a small amount of
coral calcium and glucosamine chondrontin with MSM daily with Omega-3 fatty acids every other day. Hair, nails and skin are better than ever at age 45.
SOAP's pay is higher even in the trainee/newbie stage. nm
s
oh my gosh, would you, yourself, bathe in DAWN dish soap - ouch!
no, no, no, no, no, no, no.
Vaseline works too and to rinse out use Dawn dish soap.nm
x
oh yeah, forgot that one. Worse than a soap opera. Geez! nm.
.
You're correct. Thanks! I found 2 on the SOAP transcription site
s
Pros and cons on SOAP transcription versus MediVoxx? nm
s
I am looking for samples of podiatry notes typed in SOAP format. sm
I have a potential client who would like to see some samples typed up and then let him know how much that report would cost. I charge by the line, and this is something that he is not familar with. Would appreciate about 3 or 4 reports, hopefully one of them being lengthy. TIA
Do you put "License xxxxx" on a SOAP note for signature title?

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!  


My favorite moment on a soap was years ago when Hope was marrying someone else and Bo came up riding
on his motorcycle to break up the wedding and take her away.  I always thought that was the most romantic thing in the world!  My favorite was the Christmas episodes when Mrs. Horton would put up the Christmas tree bulbs of all of the family members and it was basically like reliving the old episodes.
NEW CONTRIBUTION! Candles & Soap courtesy of Incredible Soy. Click on Santa's
/
Turn off the soap opera network and get a clue, drama queen!
That's what a lot of you around here do, find drama in otherwise innocent posts.  Get a life, get back to work.  And above all else, you call me a hypocrite and yet you sit in judgment of me.
I provide the template, I don't provide the headings though.
but I do pay them for everything that they transcribe. So, the MT has the initial template, they fill in the demographic fields, the body of text, cc information, etc. and that's what they are paid for. The body of text that the MT transcribes would include headings such as Subjective, Objective, etc., however the actual template that includes the logo, wording such as Patient Name, Date of Service, Attending Physician, etc. are not paid for. The template consists of about 8 lines total.