SOAP Notes: Getting Down and Dirty with Medical Translation

SOAP Notes:
Getting Down and
Dirty with
Medical 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
4
To replicate the style and voice of
healthcare professionals in your
medical translations.

SOAP NOTES:
AN INTRODUCTION

WHAT IS A SOAP NOTE?
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”.

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 pattern
Severity
(S)UBJECTIVE

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

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-ups
o Referrals, discharge, future appointments, etc.
o Prescriptions, monitoring
o Numbered by severity and urgency
(P)LAN

SOAP NOTES:
SECTION BY SECTION

(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 .

(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.

(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).

(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.

SOAP NOTES:
THE NITTY GRITTY

REVIEW OF SYSTEMS
o 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).

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

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.

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

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

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:

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.
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 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).

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.

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/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

QUESTIONS?

Thank you
Erin M. Lyons
elyons@biomednouvelle.com

SOAP Notes: Getting Down and Dirty with Medical Translation

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