SOAP notes
Posted By: Carla on 2007-06-20
In Reply to:
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
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SOAP notes
Subject: SOAP notes
transcribing for 7 1/2 week old child. Dictator states fontanels are flat, sound like "contrapendalence" are normal.
Can you see samples of how the other MTs handle it? Are these SOAP notes? Can you number the probs
Subject: Can you see samples of how the other MTs handle it? Are these SOAP notes? Can you number the probs
s
Nurses' notes or nurse's notes or nurses notes?
Subject: Nurses' notes or nurse's notes or nurses notes?
I am so confused on this one. I have typed it several different ways over the years. Do I really need to put any apostrophe in there at all? Thanks!
Nurse's notes reviewed or nurses notes reviewed? nm
Subject: Nurse's notes reviewed or nurses notes reviewed? nm
x
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?
...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.
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?
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
He dictates in SOAP format so that might look out of place.
Subject: He dictates in SOAP format so that might look out of place.
op notes
Here is a list from my favorites. Hope they are a little bit helpful. I think they are all still good sites.
Op note sites:
http://www.mt-stuff.com/ent.html
http://mtdesk.com/gen.shtml
http://www.medical-library.org/journals2a/tubal_ligation.htm
http://www.mtdaily.com/samples.html
http://www.nezhat.com/oplap_abst.htm
http://www-personal.umich.edu/~aalin/vitalsigns/contentappendix/cntappsamplenotes.html
op notes
Subject: op notes
I have never encountered such a rule. I don't generally listen to where the dictators want their paragraphs, though. They usually put in way too many. I start a new paragraph after the prep and drape description and a I start a new paragraph for the closing of the wounds. I add new paragraphs when the surgeon is addressing a new area. That's just my style of transcribing. I'm not saying it's the right way to do it. It just makes sense to me and I would think it is easier to read and comprehend that way.
take notes!
Subject: take notes!
Whenever I have to spend a lot of time looking something up, I make sure to write it down. It's worth it.
I don't do op notes! LOL
Subject: I don't do op notes! LOL
Subjective, Objective, Assessment, Plan=SOAP..
Subject: Subjective, Objective, Assessment, Plan=SOAP..
Twenty-five years ago, SOAP format was still the in-thing, but doctors slowly trended away from it, probably due to medical transcription and formats changing over time. They are easy to do though.
She could be saying that, referring to oatmeal soap or something like that. I'll relisten.
Subject: She could be saying that, referring to oatmeal soap or something like that. I'll relisten.
Thanks!!
Thanks on the info. Never heard of SOAP report. Always learn something new. nm
Subject: Thanks on the info. Never heard of SOAP report. Always learn something new. nm
ss
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.....
thanks - i usually do ER notes so not familiar with that!
Subject: thanks - i usually do ER notes so not familiar with that!
Resources for OP notes?
Subject: Resources for OP notes?
Is there anyone here who does operative notes and gynecology notes who could give me some websites to use for resources? I am on an OB/GYN account and have operative notes. I have trouble sometimes with the specific surgical instrument names and would greatly appreciate any help. Thanks in advance.
Resources for OP notes?
Subject: Resources for OP notes?
My suggestion would be to purchase (if you do not already have)OB/GYN, equipment and surgical word books (Steadman's) my choice and you would be equipped to better perform your job.
OP notes resources
Subject: OP notes resources
I would do that but we are on a tight budget as we just bought a house and are getting in married in september.
Paragraphs in Op notes
Subject: Paragraphs in Op notes
I have noticed that when I transcribe an Op note as the dictator dictates it, starting a new paragraph as dictated...that QA always removes the spacing between the paragraphs.
Is there some rule in transcription that you don't break an op note into paragraphs? The client profile does not say anything about this.
Thanks so much! I'm taking notes!
Subject: Thanks so much! I'm taking notes!
I have parascapular in my notes.
Subject: I have parascapular in my notes.
Think just nurses notes. IMO. nm
Subject: Think just nurses notes. IMO. nm
Nurse's notes..
Subject: Nurse's notes..
An apostrophe shows ownership. :-)
Labor and deliveryy - vaccum strength s/l clean soap
Subject: Labor and deliveryy - vaccum strength s/l clean soap
n
Does anyone know a good website for op-notes...
Hi, does anyone have any websites that are good for surgical words? I have limited books, try to use Int. for most everything. I use surg. instrument sites to look up tools, but not always successful or spend too much time looking through their quite extensive catalog. Thanks for your help...Suzy
Does anyone know a good website for op-notes...
Does anyone now a good website or two for surgical notes? I at times use a surgical instrument site but if I don't know how to spell something, I have to look through extensive catalog listings...or if I get a foreign accent and can't make out what he is saying, then I have big problems, so a site that has sample notes would be a big help too. Thanks for your help. Suzyq
Can you look at the doc's other notes and see how he words his/her followups? ...maybe something
Subject: Can you look at the doc's other notes and see how he words his/her followups? ...maybe something
s
thank you very much, I will write that in my future notes
Subject: thank you very much, I will write that in my future notes
Good luck to you then!! Op notes are a sm
Subject: Good luck to you then!! Op notes are a sm
whole nother mess!! Do you have these sites for equipment, latest things etc?
http://www.medcompare.com/
======================
Another good site:
http://www.surgical911.com/
No, I cannot confirm. I have some personal notes
Subject: No, I cannot confirm. I have some personal notes
that I make and had Segund in them.
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