A community of 30,000 US Transcriptionist serving Medical Transcription Industry

Question about SOAP notes - and headings

Posted: Jul 21, 2014

I'm curious about something and I hope you all can clarify it for me. I've always understood that when using a SOAP format, you do not use headings such as HPI, physical examination, review of systems, etc.

I've got a situation at work where initially we were to use HPI, ROS, PE, etc., no matter what the dictator said. This was for a variety of reasons but a lot of it had to do with the coders. Now, the directive is to use the heading the dictator says. My issue/question is how much intermingling of the 2 styles do you see and/or use? For example, I have one report that has Subjective, Review of systems, Past medical history, Physical Examination, and Assessment and Plan.

I recognize this may just be me being a tad uptight about formatting and consistency. Anyone have any thoughts on this?

You do it according to - What you are instructed at work

[ In Reply To ..]
You do your reports as you are instructed by your superiors, not by what we say.

You will find that things don't fit in a neat box in this business and will also change from one minute to the next depending on many factors.

We have not been told anything about this - Gathering intel to take to TBTB

[ In Reply To ..]
Before I go to my boss, I just wanted other people's opinions. Maybe I'm just anal about it and no one really cares. If that's the case, then I'll forgo talking to my boss about it. I just wondered what other people thought, that's all. No biggie.

I would not - Choose this hill to die on

[ In Reply To ..]
There really isn't a right or wrong way. Not sure how long you've been in the biz, but there is no "standard" way of doing things.

I do know that very often if there is a template, headings can't be moved or messed with. Other than that, just do as dictated, or as otherwise instructed by your superiors and/or the client. Really, save your energy with that kind of thing.

But wait, isn't this why we have the AHDI and their BOS? To provide uniformity - style and formatting?

[ In Reply To ..]
Or could it be that the AHDI is really just a bogus organization created merely make money by selling us a worthless membership to an organization that has really no bearing on the healthcare industry whatsoever. They serve to sell us a book that NOBODY outside of the MTSOs recognize. I challenge you to talk into any HIM department director in any hospital or better yet ask any doctor if he is familiar with the organization or their BOS and the answer will be "huh?"

So to answer your question, format your report the way the dictator dictates it. And definitely don't bother to ask questions on this website. You get deliberately vague answers or completely snarky responses from disgruntled MTs who hate their jobs.

Good luck to you!

Of course it is bogus - see msg

[ In Reply To ..]
Yes, AHDI is bogus. We are trying to help the poster understand that there is no such thing as "standard" or "correct." We are not being snarky.

IMO the original poster was looking for a consensus of how each individual handles - formatting.

[ In Reply To ..]
So instead of providing her with responses telling her she shouldn't be asking, why not simply says "this is how I would handle it..."

Here's my answer, I transcribe headings as dictated. If I'm told to adhere strictly to say the SOAP format. Then, when the dictator says past medical history, review of systems, social history, family history, etc. that is included under the SUBJECTIVE heading. Physical exam and lab and x-rays are included under the OBJECTIVE heading. I will combine ASSESSMENT and PLAN if that is how it's dictated, but that is the only deviation I would make from the SOAP format.

If you are told to transcribe "verbatim" then I would use whatever headings the dictator dictates. As far as formatting reports to make it easier for coders, I don't believe it is my job to make everyone elses job easier. Part of the coder job description is abstracting info from the chart. So they'll have to thoroughly read some reports to get the info they need, that's the job.

Finally, I do believe there should be industry-wide uniformity, or at the very least facility wide, as far as report formatting. The HIM director should be able to provide a physician new to the staff with guidelines on how to use the dictation system and guidelines on report type formatting, acceptable headings, etc. An individual physician should NOT be allowed to make his/her own rules and expect that the MTs to keep track of his/her personal preferences in addition to the preferences of a hundred other doctors. It's ridiculous and quite frankly it is a breeding ground for report errors. We are in a catch 22 ladies. We can't score 98% on QA evals if we have to try to remember every single except to the so-called "rules." And we can't meet productivity if we have to constantly check our account specs for each individual's preferences.

Alas, what can we do about it? I will keep looking for a way to change at least my little world. And maybe one day we will have an MT organization that actually is beneficial and serves a purpose other than lining their own pockets or equipping and educating third-world MTs on how to take my job.

PEACE!

that's an account-specific question, not general med trans question. - yes, take it up with MTSO or leads

[ In Reply To ..]
our opinions won't matter with this.

SOAP Notes - Coder

[ In Reply To ..]
When SOAP notes were first introduced they were seen as a fabulous way to improve documentation, but they turned out not to be so great. A lot of providers felt there was still a need for some more headings. Hence, you will see a mix of styles. You will encounter people who are flexible and people who are die-hard, preachy purists. However, there really are no rules and no "preferred" style.

You are fine going with whatever headings they dictate. You would be fine adding what is correct.

I am surprised that you were told the heading thing was for the coders. Coders can and should be able to use information appropriately regardless of where it is in the note. They should be able to identify elements of HPI, Chief Complaint, and anything else no matter where it is even if there are no headers at all. Even if it is in the wrong place. If yours cannot, that situation needs to be corrected because it can be a significant source of revenue loss.

Thank you. - xx

[ In Reply To ..]
Yours was the only answer that made sense for my question. I must not have been phrasing the original question well.

I appreciate your input.

My pleasure! - Coder

[ In Reply To ..]
Nothing wrong with the way you phrased the question. I was just able to see where you were going with it. It comes up now and then in coding, so I thought you might be on that track.

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