SOAP Notes: Getting Down and Dirty with Medical Translation

SOAP Notes:

Getting Down and

Dirty withMedical

Translation© Erin M. Lyons. ATA 2015, Miami.

1 To identify the structure and language used in SOAP notes and medical charts.

2 To dissect each section to identify essential terminology and acronyms.

3 To build a set of language-specific and medical terminology resources.

SOAP Notes: Getting Down & Dirty With Medical Translation

OBJECTIVES

© Erin M. Lyons. ATA 2015, Miami.

4 To replicate the style and voice of healthcare professionals in your medical translations.


SOAP NOTES:AN INTRODUCTION





WHAT IS A SOAP NOTE?


S SUBJECTIVEO OBJECTIVEA ASSESSMENTP PLAN

A SOAP note is a method of documentation employed by healthcare providers to write out notes in a patient's chart. While standard in format, style and content change with the medical specialty.

A SOAP note is a structured form of “progress note” to it ensures meaningful data, rather than narrative charting,

such as "patient appears to be resting”.


A QUICK LOOK


S SUBJECTIVE

O OBJECTIVE

A ASSESSMENT

P PLAN


This is the patient’s chief complaint (CC) or the history of present illness (HPI).o This is the purpose of the patient’s visit

or hospitalisation.o The “OLD CARTS” mnemonic device is used by

doctors to help guide them in gathering subjective information:

Onset Character (sharp, dull, etc.) Location Alleviating/Aggravating factors Duration Radiation

Temporal patternSeverity

(S)UBJECTIVE




Information gathered by the doctor, through observation or measurement, including:o Vital signs (height weight, temperature, BP, etc.)o Physical examo Laboratory testso Prescriptions

(O)BJECTIVE


This is the medical diagnosis or the purpose of the visit/hospitalisation:o Assessment of the situation, even if obvious

based on subjective/objective statements.o Includes possible and likely aetiologies.o Does not repeat the subjective and objective

portions, but takes key points and puts them together into a conclusion.

(A)SSESSEMENT




What the doctor will do to treat the patient’s concerns and based on the assessments:o Ordering lab tests, radiological work-upso Referrals, discharge, future appointments, etc.o Prescriptions, monitoringo Numbered by severity and urgency

(P)LAN


SOAP NOTES:SECTION BY SECTION






(S)UBJECTIVEo When writing the Chief Complaint (CC), clearly indicate the

reason for visit (not necessarily using complete sentences).o Pay attention to the History of Present Illness (HPI), as it may

provide clues for puzzling sections later on.

“Le patient s'est présenté pour douleur de l'HCD” (FR)“Patient presents for pain in the right upper quadrant (RUQ)”

DO DON’T

Use the present tense. Use past tense or mix tenses.Expand acronyms for 1st use. Fail to translate acronyms.

Research correct usage for your target. Directly translate acronyms.

Check your terminology:“hypochondre droit (HCD)” can be translated into EN as “right hypochondrium”, but “right upper quadrant” is

correct usage .



(O)BJECTIVEo The Review of Systems (ROS) dictates the order of general

headings [General – Skin – HEENT – Neck – Respiratory – Cardiovascular – Abdomen – Extremities – Neurological].

o Use ICD-10 Codes to help narrow down correct medical terminology. (https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx)

“Dolor intenso en la FID por la compresión” (ES)“Acute pain in the right lower quadrant (RLQ) on palpation”

DO DON’TStay objective: signs and symptoms. Use “diagnostic” language.

Use plain language. Turn phrases into wordy sentences.

Use correct register (doctor-facing). Use lay medical terminology.



(A)SSESSMENTo Draws on the Subjective and Objective portions to reach a

Differential Diagnosis (DD).o Be careful of the order. Assessments should be written in the

order of most to least likely diagnosis and secondary diagnoses.

“Possibilities include acute appendicitis, R ovarian torsion, Mittelschmerz, ectopic pregnancy, PID, or a viral syndrome. Given the lack of d/c and the very minimal cervical motion

tenderness PID is less likely”.

DO DON’TBe methodical with conjunctions. Beware of conjunctions that do not

have the same “logical link” in the source and target.

Handle acronyms appropriately: The target audience of your translation may not be a healthcare

professional. Expand acronyms (d/c = diarrhoea/constipation) and do not assume your target will know even obvious

signs/symbols (“R” for “Right).



(P)LANo Often a list, this should be well organised. o Even though abbreviations are common in prescriptions,

translation protocol should avoid Latin (TID for “three times daily” or PO for “orally”), unless otherwise specified.

1. Check abdominal/pelvic CT to look for evidence of obstruction or inflammation.

2. A surgical consultation will be requested.

DO DON’TUse imperative or present test. Use passive voice.

Double check Rx names, doses. Use Latin in prescriptions.

Plan may be written by system/disease for complex cases and multiple therapies/follow-up.


SOAP NOTES:THE NITTY GRITTY



REVIEW OF SYSTEMSo An inventory of body systems obtained through a series of

questions seeking to identify signs and/or symptoms.



REVIEW OF SYSTEMS



ROS: WORDS & PHRASES


o Physicians use specific terminology when dictating/writing ROS notes (http://www.medicaltranscriptionwordhelp.com/review-of-systems-phrases-and-words-for-medical-transcriptionists).


VITALSo The four primary vital signs are:

1. Body temperature

2. Heart rate/pulse

3. Respiratory rate

4. Blood pressureo It is also standard to record height, weight and BMI.o The “fifth” vital sign includes: pain, Glasgow coma scale (GCS),

pulse oximetry and blood glucose.o The “sixth” vital sign incudes: end-tidal CO2, functional status,

shortness of breath and gait speed.


Be sure to learn the acronyms, symbols and shorthand associated with your source and language combinations.


ACRONYMS/ABBREV.TYPE EXAMPLEAbbreviations Paediatr. = paediatricsAcronyms NICU = Neonatal Intensive Care UnitClinical Trials JUPITER = Justification for the Use of statins in

Prevention: an Intervention Trial Evaluating Rosuvastatin

Foreign Retained OKT4/OKT8 (HIV+), EGF = Epidermal Growth Factor

Handwriting HCT 250 mg vs. HCTZ 50 mgInversions MRI (EN) = IRM (FR)Latin h.s. = hora somni = at bedtimeMedical Argot DCD = décédé (FR), VIP = Very Intoxicated

PersonVariable Units Multiple Sclerosis (MS) vs. Sclérose En Plaques

(SEP)

o Identifying the type of acronym or abbreviation may help you in the translation process.

© Erin M. Lyons. ATA 2015, Miam i.


LABSo Learn the relevant lab tests for your language combination(s)

(including all appropriate acronyms and abbreviations).o https://labtestsonline.org/map/gindexo The ten most common blood tests:

1. Complete Blood Count (CBC)

2. Differential

3. Blood Glucose (GB)

4. Electrolyte Panel

5. Erythrocyte Sedimentation Rate (ESR)

6. Long-winded Enzyme-Linked Immunosorbent Assay (ELISA)

7. Cholesterol

8. Karyotyping

9. Blood culture

10. Blood typing© Erin M. Lyons. ATA 2015, Miami.


IMAGINGo Imaging tests are typically ordered in the “Assessment” section.o Be sure you are familiar with the most common imaging tests:

Computed tomography (CT) scan Magnetic resonance imaging (MRI) scan X-ray and other radiographic tests Mammography Nuclear medicine scans Ultrasound



SOAPNOTE.ORGo www.soapnote.org has numerous helpful tools for understanding

SOAP notes.o If you find yourself stuck decoding an imaging test. Use the

MRI/CT Scan Decision Tool:



PRESCRIPTIONSo The “Plan” section is the opportunity to reconcile the patient’s

current/past medications and to make applicable updates and changes.

o Refer to earlier sections and/or history for clues.


P: 1. Increase Novolin 70/30 to 22 units Q AM and 16 units Q PM.

Substitute atenolol for Metoprolol at 50 mg PO daily since Metoprolol not available in clinic. Reinitiate Lisinopril 20 mg PO daily and HCTZ 25 mg 1/2 tab PO Q AM.

2. Rerequesting Clopidogrel through drug assistance as pt has finished supply today. Continue current dose of ranitidine since 150 mg PO daily.

3. Will initiate statin therapy pending results of fasting blood work. Encourage low fat, low chol, low NA diet. Discussed lowering intake of tortillas, beans, and rice, and increase skinless meats and fresh vegetables.

Don’t be afraid to double check!Do they mean:

“HCT 250 mg” (hydrocortisone 250 mg) or “HCTZ 50 mg” (hydrochlorothiazide 50 mg)?


CHECKLIST SOAP notes are intended to improve communication among

healthcare providers using a specific notation system.

The structured system will provide you clues to narrow in on confusing medical terminology, acronyms, etc.

SOAP notes are universal: learn the preferred structure and terminology for your language combination.

SOAP notes are not written for patients, use appropriate physician- or healthcare provider-facing terminology.



SOAP NOTES:STYLE AND REGISTER





WHO IS YOUR TARGET?


o Physicians, nurses, specialists => Intended for healthcare professionals and not patients/caretakers!

o Fact-based; avoid flowery or embellished language.o Use clear and concise vocabulary, physicians are not interested in

winding narratives.o Standard acronyms are fine (e.g., CT scan), but expand the

1st instance of others (e.g. BS = breath sounds, blood sugar or bowel sounds).

Be careful with punctuation:Dashes (-), slashes (/), full stops (.), commas (,), etc. have

different meanings in different languages.


DRAFTING TIPSo Be careful about the number of acronyms/

abbreviations used.o Remember to refer to the physician in the third person

(e.g., the surgeon, the physician, the gastro-enterologist), even when the first person is used in the note (i.e., I, we).

o Use succinct subject-verb-object language and do not embellish.

o Use an appropriate register (formal) and medical terminology (not lay terms).



SOAP TERMINOLOGY

MEDICAL TERM LAY TERMABDOMEN STOMACHANALGESIC PAIN RELIEVERCARCINOGENIC CANCER-CAUSINGINVESTIGATIONAL DRUG STUDY DRUGIMMUNOLOGICAL EFFECTS ON THE IMMUNE SYSTEMMETABOLISE BREAK DOWNRENAL KIDNEYTHROMBUS BLOOD CLOTRESPIRATION BREATHING

o Appropriate medical terminology should be used in SOAP notes.o In English, this often means using the Latin cognate.



ICD-10: A GOLDMINE


o International Statistical Classification of Diseases and Related Health Problems.

Excellent tool to research terminology and systems.


REVERSE SEARCH


o Use a reverse plain language search to hone in on the right terms and register.


SOAP NOTES:A CASE STUDY






SUBJECTIVE

History includes narrative of patient’s complaints, symptom dimensions.



SUBJECTIVE

Subjective section also includes social history, known allergies, current medications/compliance.



OBJECTIVE

Physical exam and related laboratory tests, imaging.



ASSESSMENT

Assessment is succinct; supported by prior objective findings.



PLAN


REMINDERS


1. Practice being succinct: use plain language to give a snapshot of a patient at a particular moment in time.

2. Avoid excessive use of acronyms or abbreviations; including them only augments confusion.

3. Document your research; don’t waste time researching twice.

4. Read online SOAP notes to get a feel for the standard physician style in your source-target combination.


RESOURCES


Medilexicon Medical Abbreviations/Terminology

http://www.medilexicon.com

University of Michigan Plain Language Dictionary

http://www.lib.umich.edu

Tool Box for the Medical Translator (FR/EN)

FR-EN/EN-FR Medical Glossary & Resources

http://www.groupetraduction.ca/documents/ToolBox.pdf

Maxwell Quick Medical Reference

Doctor’s Quick Medical Reference

Amazon/bookseller

Pocket medicine: The Massachusetts General Hospital Handbook of Internal Medicine

Pocket Handbook of “Essentials”

Amazon/bookseller


QUESTIONS?


Thank you


Erin M. [email protected]


Health & Medicine

SOAP Notes: Getting Down and Dirty with Medical Translation