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SOAP note question - Dusty

Posted: Jul 11, 2012

I hope this is correct board to use.

Okay, I have done both but I want to know officially which one is correct. In a SOAP note if the doctor dictates "Clinically the patient has a herniated disc" does this go under objective or assessment. Thanks for your help on this.

SOAP note - MT

[ In Reply To ..]
It really depends on when the doctor dictates it in the note. If at the beginning, I would put it under subjective but, if it's towards the end, under assessment. When doctors really don't follow a pattern in their dictations, it's sometimes hard...just your own determination.

These are questions that should really - be addressed

[ In Reply To ..]
to your instructors. That's what you're paying them for.

When you are working, your employer will provide you with samples so you can made these decisions for yourself.

Agree, Ask Instructors - nm

[ In Reply To ..]
nm

Instructors? - Dusty

[ In Reply To ..]
What instructors are you talking about? I transcribe for doctors. I am wanting opinions about this. And no, I have not been provided samples by the doctors.

Since the questions - were so very basic

[ In Reply To ..]
it was only natural that working MTs would have to consider that they were from a student.

The best thing to do would be to ask for samples so you know how they want it done.

Maybe... - MT

[ In Reply To ..]
...because you said you did it both ways, thought maybe you submitted tests/assignments with 2 different versions.

You do have to ask your account, sorry we can't help with that. It's up to your doctors or agency you work for. My first guess, though, would be the assessment, but you do need to take it in context of where it's dictated.

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