When an established patient is seen for a repeat visit, chart notes are dictated which include the reasons for the current visit, an assessment of the patient’s condition along with the changes since the previous visit, and additional treatment provided or planned. Chart notes are dictated in various formats such as a History and Physical Examination (H&P) report with similar headings and less depth, as a single paragraph with few sentences, or using SOAP format. As chart notes are short, medical transcription is performed for multiple notes as a single document and will be segregated after physician review. However, the most common method of dictating the chart note is the SOAP format as it can be tailored to any kind of study or study visit. It also meets medical record needs for continuing care of the patient and the source documentation requirements of the study.
SOAP stands for Subjective, Objective, Assessment and Plan. Since the chart notes are short, dictators use the letters S, O, A and P instead of full headings and most medical transcriptionists transcribe chart notes with these letters as headings. Here is a detailed explanation of the SOAP acronym along with an example of a SOAP Note for a substance use case:
- Subjective – This component describes how the patient has been doing since the last visit and also includes the current visit. It may include no complaints (I feel good) from the patient and specific current complaints (I have low back pain) as well as the complaints (I had diarrhea a few weeks ago) that occurred in the interim and have been resolved.
S: Mr. X has been well since last visit and reports no complaints today. He states that he has not used any drugs since the last visit including IV drugs.
- Objective – The objective component includes vital signs such as temperature, blood pressure, pulse and respiration, documentation of the physical examination performed, results of laboratory or other studies done during the visit. This section may include a sentence or two about the relevant body part or refer to another document or stuffed with jargon, abbreviations and acronyms to make the documentation as small as possible, which the behavioral medicine transcription service provider should document exactly as dictated. Previous reports may have to be referred to in order to understand the terms.
O: T: 37 C (by mouth); BP: 130/68; P: 70; R: 14
Exam of arms: well healed linear scars along the antecubital area.
- Assessment – This section refers to short assessment of the patient by the clinician based on the subjective information and objective findings gathered earlier.
A: 40-year old man enrolled in HPTN XYZ. No evidence of current IV drug use
- Plan – This section includes the recommendations of the clinician regarding the patient’s condition. It may include referral to a specialist, name of drug prescribed, amount dispensed and dosing instructions, follow-up instructions, and date of next appointment.
P: Continue with counseling sessions. Client is scheduled to return for Visit 7 on November 12. Client is also reminded to contact or return to clinic if there are any problems before that date
The assessment and Plan section can be separated or combined (A/P). It is not necessary to number multiple diagnoses unless specifically requested. The transcriptionist also does not need to expand diagnoses acronyms in SOAP notes as in other reports. Some dictators may use different sets of abbreviations to refer the same thing such as:
- CC: Acronym for chief complaint, equivalent to subjective
- PX or PE: Shorthand for physical examination, equivalent to objective
- DX: Abbreviation for diagnosis, equivalent to assessment
- RX: Abbreviation for prescription, in this case prescribed treatment plan
Sometimes, a physician/nurse may leave certain sections or mix and match headings (for example, Chief Complaint may be dictated in place of or in addition to Subjective). Headings dictated should be transcribed unless there is a specific instruction to do otherwise.
It is also important to note that there would be certain differences in the information added in SOAP notes in different clinical settings. For example, the Lachman test, a special orthopedic test for ACL injury, may be added to the Objective section by the physical therapist or orthopedic doctor, but not by a nurse.