Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

SOAP Notes: Getting Down and Dirty with Medical Translation

9,696 views

Published on

Progress notes and patient records are the medical translator's bread and butter, but this doesn't prevent even the most experienced medical translators from getting burnt. We'll take a closer look at the SOAP (Subjective, Objective, Assessment, Plan) format to understand how doctors think. We'll use the tool to understand why "BS" could mean "blood sugar," "breath sounds," or "bowel sounds." We'll also build a kit of multilingual resources for the review of systems, lab reports, etc. Finally, we'll address capturing succinct source-language style in a translation that is meaningful and not unduly conservative.

Published in: Health & Medicine
  • Try This Simple 7 Second Daily Ritual For Yourself Here ✄✄✄ http://tinyurl.com/y33eq8tt
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • 7 Second Daily Ritual Melts Stubborn Fat While You Sleep ☺☺☺ http://tinyurl.com/y33eq8tt
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • My brother found Custom Writing Service ⇒ www.HelpWriting.net ⇐ and ordered a couple of works. Their customer service is outstanding, never left a query unanswered.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • 7 second ritual melts 62 pounds of fat ☀☀☀ https://bit.ly/2PJu978
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • 7 Second Daily Ritual Melts Stubborn Fat While You Sleep ❤❤❤ http://tinyurl.com/y33eq8tt
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

SOAP Notes: Getting Down and Dirty with Medical Translation

  1. 1. SOAP Notes: Getting Down and Dirty with Medical Translation © Erin M. Lyons. ATA 2015, Miami.
  2. 2. 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.
  3. 3. SOAP Notes: Getting Down & Dirty With Medical Translation SOAP NOTES: AN INTRODUCTION © Erin M. Lyons. ATA 2015, Miami.
  4. 4. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami.
  5. 5. SOAP Notes: Getting Down & Dirty With Medical Translation WHAT IS A SOAP NOTE? © Erin M. Lyons. ATA 2015, Miami. S SUBJECTIVE O OBJECTIVE A ASSESSMENT P 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”.
  6. 6. SOAP Notes: Getting Down & Dirty With Medical Translation A QUICK LOOK © Erin M. Lyons. ATA 2015, Miami. S SUBJECTIVE O OBJECTIVE A ASSESSMENT P PLAN
  7. 7. SOAP Notes: Getting Down & Dirty With Medical Translation 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 pattern Severity (S)UBJECTIVE © Erin M. Lyons. ATA 2015, Miami.
  8. 8. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami. Information gathered by the doctor, through observation or measurement, including: o Vital signs (height weight, temperature, BP, etc.) o Physical exam o Laboratory tests o Prescriptions (O)BJECTIVE
  9. 9. SOAP Notes: Getting Down & Dirty With Medical Translation 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 © Erin M. Lyons. ATA 2015, Miami.
  10. 10. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami. What the doctor will do to treat the patient’s concerns and based on the assessments: o Ordering lab tests, radiological work-ups o Referrals, discharge, future appointments, etc. o Prescriptions, monitoring o Numbered by severity and urgency (P)LAN
  11. 11. SOAP Notes: Getting Down & Dirty With Medical Translation SOAP NOTES: SECTION BY SECTION © Erin M. Lyons. ATA 2015, Miami.
  12. 12. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami.
  13. 13. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami. (S)UBJECTIVE o 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. “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 .
  14. 14. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami. (O)BJECTIVE o 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) “Acute pain in the right lower quadrant (RLQ) on palpation” DO DON’T Stay objective: signs and symptoms. Use “diagnostic” language. Use plain language. Turn phrases into wordy sentences. Use correct register (doctor-facing). Use lay medical terminology.
  15. 15. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami. (A)SSESSMENT o 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. DO DON’T Be 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).
  16. 16. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami. (P)LAN o 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. DO DON’T Use 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.
  17. 17. SOAP Notes: Getting Down & Dirty With Medical Translation SOAP NOTES: THE NITTY GRITTY © Erin M. Lyons. ATA 2015, Miami.
  18. 18. SOAP Notes: Getting Down & Dirty With Medical Translation REVIEW OF SYSTEMS o An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms. © Erin M. Lyons. ATA 2015, Miami.
  19. 19. SOAP Notes: Getting Down & Dirty With Medical Translation REVIEW OF SYSTEMS © Erin M. Lyons. ATA 2015, Miami.
  20. 20. SOAP Notes: Getting Down & Dirty With Medical Translation ROS: WORDS & PHRASES © Erin M. Lyons. ATA 2015, Miami. o Physicians use specific terminology when dictating/writing ROS notes (http://www.medicaltranscriptionwordhelp.com/review- of-systems-phrases-and-words-for-medical-transcriptionists).
  21. 21. SOAP Notes: Getting Down & Dirty With Medical Translation VITALS o The four primary vital signs are: 1. Body temperature 2. Heart rate/pulse 3. Respiratory rate 4. Blood pressure o 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. © Erin M. Lyons. ATA 2015, Miami. Be sure to learn the acronyms, symbols and shorthand associated with your source and language combinations.
  22. 22. SOAP Notes: Getting Down & Dirty With Medical Translation ACRONYMS/ABBREV. TYPE EXAMPLE Abbreviations Paediatr. = paediatrics Acronyms NICU = Neonatal Intensive Care Unit Clinical 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 mg Inversions MRI (EN) = IRM (FR) Latin h.s. = hora somni = at bedtime Medical Argot DCD = décédé (FR), VIP = Very Intoxicated Person Variable 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.
  23. 23. SOAP Notes: Getting Down & Dirty With Medical Translation LABS o Learn the relevant lab tests for your language combination(s) (including all appropriate acronyms and abbreviations). o https://labtestsonline.org/map/gindex o 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.
  24. 24. SOAP Notes: Getting Down & Dirty With Medical Translation IMAGING o 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 © Erin M. Lyons. ATA 2015, Miami.
  25. 25. SOAP Notes: Getting Down & Dirty With Medical Translation SOAPNOTE.ORG o 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: © Erin M. Lyons. ATA 2015, Miami.
  26. 26. SOAP Notes: Getting Down & Dirty With Medical Translation PRESCRIPTIONS o 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. © Erin M. Lyons. ATA 2015, Miami. 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)?
  27. 27. SOAP Notes: Getting Down & Dirty With Medical Translation 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. © Erin M. Lyons. ATA 2015, Miami.
  28. 28. SOAP Notes: Getting Down & Dirty With Medical Translation SOAP NOTES: STYLE AND REGISTER © Erin M. Lyons. ATA 2015, Miami.
  29. 29. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami.
  30. 30. SOAP Notes: Getting Down & Dirty With Medical Translation WHO IS YOUR TARGET? © Erin M. Lyons. ATA 2015, Miami. 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.
  31. 31. SOAP Notes: Getting Down & Dirty With Medical Translation DRAFTING TIPS o 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). © Erin M. Lyons. ATA 2015, Miami.
  32. 32. SOAP Notes: Getting Down & Dirty With Medical Translation SOAP TERMINOLOGY MEDICAL TERM LAY TERM ABDOMEN STOMACH ANALGESIC PAIN RELIEVER CARCINOGENIC CANCER-CAUSING INVESTIGATIONAL DRUG STUDY DRUG IMMUNOLOGICAL EFFECTS ON THE IMMUNE SYSTEM METABOLISE BREAK DOWN RENAL KIDNEY THROMBUS BLOOD CLOT RESPIRATION BREATHING o Appropriate medical terminology should be used in SOAP notes. o In English, this often means using the Latin cognate. © Erin M. Lyons. ATA 2015, Miami.
  33. 33. SOAP Notes: Getting Down & Dirty With Medical Translation ICD-10: A GOLDMINE © Erin M. Lyons. ATA 2015, Miami. o International Statistical Classification of Diseases and Related Health Problems. Excellent tool to research terminology and systems.
  34. 34. SOAP Notes: Getting Down & Dirty With Medical Translation REVERSE SEARCH © Erin M. Lyons. ATA 2015, Miami. o Use a reverse plain language search to hone in on the right terms and register.
  35. 35. SOAP Notes: Getting Down & Dirty With Medical Translation SOAP NOTES: A CASE STUDY © Erin M. Lyons. ATA 2015, Miami.
  36. 36. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami.
  37. 37. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami. SUBJECTIVE History includes narrative of patient’s complaints, symptom dimensions.
  38. 38. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami. SUBJECTIVE Subjective section also includes social history, known allergies, current medications/compliance.
  39. 39. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami. OBJECTIVE Physical exam and related laboratory tests, imaging.
  40. 40. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami. ASSESSMENT Assessment is succinct; supported by prior objective findings.
  41. 41. SOAP Notes: Getting Down & Dirty With Medical Translation © Erin M. Lyons. ATA 2015, Miami. PLAN
  42. 42. SOAP Notes: Getting Down & Dirty With Medical Translation REMINDERS © Erin M. Lyons. ATA 2015, Miami. 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.
  43. 43. SOAP Notes: Getting Down & Dirty With Medical Translation RESOURCES © Erin M. Lyons. ATA 2015, Miami. Medilexicon Medical Abbreviations/Terminol ogy 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.c a/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
  44. 44. SOAP Notes: Getting Down & Dirty With Medical Translation QUESTIONS? © Erin M. Lyons. ATA 2015, Miami.
  45. 45. Thank you SOAP Notes: Getting Down & Dirty With Medical Translation Erin M. Lyons elyons@biomednouvelle.com © Erin M. Lyons. ATA 2015, Miami.

×