There are many different types of medical transcription reports but the most basic report is the SOAP note. SOAP stands for Subjective, Objective, Assessment and Plan. The note will be typed with these headings in order beginning with Subjective.
Subjective:
The subjective portion of the note is where the physician describes the complaint and symptoms of the patient from the patient’s point of view. This is the history or store of the illness or problem.
Objective:
The Objective section is the next section and it is basically the physical examination and other findings from the physician’s point of view. This section can include the physical exam, laboratory results, radiological results and results from other medical tests.
Assessment:
The next section is the Assessment. This is where the physician dictates the diagnosis of the patient’s condition. The Assessment section is often in the form of a numbered list and can include diagnostic codes. The Assessment or Diagnosis section should not contain any abbreviations but all terms should be spelled out completely.
Plan:
The final section is the Plan. This section describes the treatment and follow-up plans for the patient.
Here is a sample SOAP note report:
SUBJECTIVE:
The patient is an 82-year-old female who presents today complaining of chest pain. She states the pain begain at 5:00 this morning and lasted for 15 minutes. The pain recurred at 7:00 a.m. which prompted her to visit the emergency room. She had no shortnes of breath or diaphoresis with this chest pain. She has never had pain like this in the past. She is not a smoker and does not consume alcohol. Patient also complains of a headache that started last night.
OBJECTIVE:
GENERAL: Well-developed, well-nourished elderly female in no acute distress.
VITAL SIGNS: Blood pressure 120/80, pulse 78, respirations 20, oxygen saturation 99% on room air.
HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular muscles intact. Nose and throat are clear.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: No clubing, cyanosis or edema.
NEUROLOGICAL: Cranial nerves II-XII intact.
ASSESSMENT:
1. Chest pain, unknown etiology.
2. Headache.
PLAN:
1. Check EKG, serial cardiac enzymes and chest x-ray.
2. Admit to the hospital for further evaluation.
Again, this is the most basic of medical transcription note formats. Other formats will be discussed in future articles including sample dictations.
