What Does Soap Stand for in Medical Records

For medical translators, a closer examination and dissection of the SOAP note format is key to understanding how doctors think.

Progress notes and patient records are the medical translator's bread and butter, but this does not prevent even the most seasoned medical translators from making mistakes. While most medical translators are experienced in translating these documents, failure to fully understand the nuances of their structure, language, and rationale limits a translator's ability to replicate the style and voice of health care practitioners. Furthermore, it creates roadblocks when attempting to decipher strings of murky acronyms and seemingly unintelligible scribbles.

The SOAP note (Subjective, Objective, Assessment, and Plan) is a basic template for documentation employed by health care providers to write out notes in a patient's chart. It has four sections. A closer examination and dissection of the SOAP note format is key to understanding how doctors think. A thorough understanding of this tool makes it clear why "BS" could mean "blood sugar," "breath sounds," or "bowel sounds" (among others), depending on the context. If followed correctly, this linear format can point translators to the correct terminology for bodily systems or examinations, regardless of seemingly impenetrable and opaque source language.

SOAP Notes: Section by Section

When we speak about SOAP notes we're not talking about something you wash with or a report on clinical hygiene, but rather the standardized format for writing medical notes that was developed in the 1960s to create a universal methodology and format for medical charting. While there are many formats for documenting patient progress, the advent of electronic medical records has only further cemented the SOAP note format as the basis for modern clinical reasoning and the means for health care providers to communicate and provide evidence of patient contact. While the style and content may vary slightly based on the medical specialty or health care center, the Subjective-Objective-Assessment-Plan structure remains unchanged during the charting process.

Subjective

The SOAP note format starts with the subjective component. This section of the medical record is considered "subjective," since it's based on the doctor's initial interview with the patient and the patient's chief complaint (CC) or history of present illness (HPI). Essentially, this is the reason for the patient's visit or hospitalization. While it may seem straightforward, this section can often be murky and truncated, particularly when a patient has a long, complicated, and/or known history, and when the translator has only been given an excerpt of the medical record.

In such cases, it's helpful to know what information physicians and nurses are looking for when gathering and compiling information regarding the patient's CC. This is where the classic "OLD C(H)ARTS" medical school mnemonic device is particularly useful for translators. The mnemonic below refers to the information a physician should ask the patient about before referring to the patient's previous "old charts."

• Onset
• Location
• Duration
• CHaracter (sharp, dull, etc.)
• Alleviating/Aggravating factors
• Radiation
• Temporal pattern (every morning, all day, etc.)
• Symptoms associated

Understanding that health care practitioners are seeking to record these eight attributes of symptoms will help translators put on their Sherlock-style thinking caps to fill in any glossed source notes or illegible handwriting. While translators should be warned that complete sentences are not necessarily required when translating SOAP notes, they should be reminded that the message must remain clear and succinct.

Health care practitioners are not writers and have a tendency to mix tenses and acronyms. Translators should remember to use the present tense as much as possible in SOAP notes when translating a provider's observations, although other tenses may be necessary to show a chronology of events. Furthermore, it's good practice to expand acronyms the first time they are used. (For example, PID should be written as "PID [pelvic inflammatory disease]" the first time it occurs in a note, but "PID" will suffice in the rest of the document without the need for expansion.)

In addition, translators should be careful not to translate acronyms directly, but rather to expand them and research usage before choosing (or not choosing) an equivalent acronym. For example, "HCD [hypochondre droit]" is literally "right hypochondrium" in English. While theoretically this should be understood, in actual practice physicians use "right upper quadrant" or "RUQ." Translating "HCD" as "RHC" would only cause confusion and could even be mistaken for "renal hyatid cyst" or "right hemicolectomies," among others.

Objective

As opposed to the subjective section, the objective section of the SOAP note is based on objective data gathered through observation and measurements, such as vital signs (height, weight, blood pressure, etc.), physical exam, laboratory tests, or imagery. The objective section is often based on the review of systems (or ROS), which dictates the general order of subheadings in the note and literally moves from head to toe. This is why it's important to remember the following order of the review of systems when reading notes (general, skin, head, eyes, ears, nose, throat, neck, respiratory, cardiovascular, abdomen, extremities, neurological), since these are often represented by symbols in handwritten notes. An easy example would be a heart symbol for cardiovascular (Figure 1), but a symbol that might be less clear would be two triangles to signify lungs/pulmonary.

The World Health Organization ICD-10 codes are another useful resource for translators struggling to narrow down appropriate terminology for the signs and symptoms that fill up this section of the SOAP note.¹ Merely entering a general term, such as "pulmonary," in the search box will generate a complete list of pulmonary-related diseases, their codes, and precise descriptions. The official ICD-10 is available in both English and French, while other languages are available on local country sites.

A final resource for the objective section is www.soapnote.org, a site that provides templates for a variety of common exams, such as those dealing with burns, motor vehicle accident history, cardiac risk, and a Thrombolysis in Myocardial Infarction (TIMI) risk score. These templates are invaluable for both experienced and novice medical translators, as they are framed for physicians, thus helping translators generate more authentic and transparent translations.

Figure 1: A standard handwritten SOAP note (French), illustrating the need to decipher acronyms, symbols, and the review of systems.

Assessment

The name of the third section, assessment, should not be confused with assessments or tests ordered, which would be found in the objective section. Rather, this section is where we find the medical diagnosis for the CC, or reason for hospitalization. This is where the physician assesses the situation and condition of the patient, based on the subjective and objective data gathered previously. This section is generally written in descending order of the severity of symptoms and may also include hypothetical language when referring to possible or likely etiologies of the disease.

Translators should pay particular attention to the modal verbs used (e.g., could, should, would, might), since diagnoses and etiologies may not always be clear and the differential diagnosis may merely be a point of departure for further tests and procedures. It's vital that the translator remain as faithful to the source language as possible in terms of degrees (e.g., very, slightly, mild, severe) and that a correct doctor-facing register be employed (i.e., using Latin terms, such as "myocardial infarction" rather than "heart attack," or "urticarial" rather than "hives.")

Finally, this section is also likely to contain the results of any laboratory tests ordered. A useful resource for translators (although not translation-specific) is Lab Tests Online.² This site provides a glossary and cross-references for tests and results by symptom, condition, and screening panel.

Plan

The final section of the SOAP note consists of the next steps to be taken to treat the patient's concern(s), based on the assessment. This may include ordering lab tests, radiological work-ups, referrals, check-ups, prescriptions, and monitoring. As in the assessment section, the plan, which may even be a bulleted list, tends to be numbered in descending order of severity and/or urgency.

This section is often a bit sloppy in the source language, riddled with mixed tenses and typos. For example, if the plan is in list format, translators should opt for the imperative. Also, do not rely on the source language for the correct spelling of drug names or medical devices, and beware of your own spell checker, which may automatically correct drug names that are very close to "real" English words.

Finally, beware of the use of Latin acronyms in prescriptions. For example, the use of "TID" for "three times daily" or "h.s." for "at bedtime" may be commonly used, but SOAP notes may often be reviewed by non-medical professionals as part of clinical trial adverse event reporting or insurance claims. Therefore, it's a good idea to keep the language as "clean" as possible.

Translating SOAP notes certainly requires technical accuracy, but translators should also be facilitating the communication of medical information, while remaining faithful to the meaning of the source language. To help achieve this goal, here a few key things to keep in mind:

• Practice being succinct: use plain language to give a snapshot of a patient at a particular moment in time.
• Avoid excessive use of acronyms or abbreviations. Including them only augments confusion.
• Document your research: don't waste time researching twice.
• Read online SOAP notes to get a feel for the standard physician style in your source-target combination.

Above All, Be Succinct

Understanding the structured system of the SOAP note is essential for translators to maintain a global view of the translation at hand. In medical translation, it's very easy to get bogged down in terminology and trapped on the word level, while losing sight of the purpose of the document. It can be difficult for translators to get a feel for the register that is required in these types of patient records. But remember, SOAP notes are neither literature, nor a shopping list. Succinct and plain language facilitates medical communication and accurately give a snapshot of the patient's condition at a specific point in time. Excessive use of acronyms or abbreviations and hedging language are a disservice to medical communication. Proper research, strong language, and a physician-facing register will help guide translators toward accurate and fact-based translations that read like a professional document and not like a translation.

Notes

1. "The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines" (Geneva: World Health Organization, 1992), www.who.int/classifications/icd/en/bluebook.pdf.
2. Index of Glossary of Terms (American Association for Clinical Chemistry), https://labtestsonline.org/map/gindex.

Top Resources for SOAP Notes

Maxwell, Robert W. Maxwell Quick Medical Reference Lab Coat/Desk Size Edition (Maxwell Pub Com, 2012), http://bit.ly/Maxwell-Medical.

"Medical Dictionaries, Drugs, and Medical Searches" (MediLexicon International Ltd.), www.medilexicon.com. (Search under the headings "Medical Dictionary," "Medical Abbreviations," and "Other Search Engines.")

Sabatine, Marc S. Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine (Philadelphia: Lippincott Williams & Wilkins, 2004), http://bit.ly/pocket-medicine.

SOAPNote, www.soapnote.org. (Provides templates for a variety of common exams)

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Erin M. Lyons is a French>English and Italian>English translator, medical writer, and consultant based in Stockholm, Sweden. She is the owner of BiomedNouvelle and an adjunct professor of translation at the University of Maryland. Her primary areas of focus include clinical research, medical devices, and cosmetic products. She is also working to develop BabelNouvelle, a mobile-based translation technology to facilitate medical services in the developing world. She has a BA from the University of Chicago and an MA in translation from the Middlebury Institute of International Studies at Monterey. Contact: elyons@biomednouvelle.com.

What Does Soap Stand for in Medical Records

Source: https://www.atanet.org/resources/soap-notes-getting-down-and-dirty-with-medical-translation/

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