17 October 2008

Types of transcribed reports

Medical transcriptionists type a variety of reports. One report type is the SOAP note. SOAP is an acronym for Subjective, Objective, Assessment, and Plan. Typically a note such as this might be dictated by a doctor in a clinic setting. The doctor would enumerate the patient's complaints or reasons for being seen, then outline what his examination of the patient revealed. That is the Subjective and Objective portion. The Assessment would indicate what his conclusions were, and the Plan portion would detail what steps are needed to rectify the problem, whether further testing is needed, changes in diet or lifestyle, a consultation by a specialist, a diagnostic or surgical procedure, medication, etc. These types of reports can range from one or two sentences under each heading to multiple pages in length.

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