Objectives: © Erin M. Lyons. ATA 2015, Miami

SOAP Notes: Getting Down & Dirty With Medical Translation
OBJECTIVES
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.
To build a set of language-specific
3
and medical terminology resources.
To replicate the style and voice

4 of healthcare professionals in
your medical translations.
© Erin M. Lyons. ATA 2015, Miami.

WHAT IS A SOAP
NOTE? 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,
S SUBJECTIVE
OBJECTIVE
O ASSESSMENT
PLAN
A
P
(S)UBJECTIVE
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
Radiation
Duration Temporal pattern
Severity
(O)BJECTIV
E
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

(A)SSESSEMENT
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.

PLAN
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

SOAP NOTES:
SECTION BY
SECTION


(S)UBJECTIVE
“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.

(O)BJECTIV
E– Neck – Respiratory –
o The Review of Systems (ROS) dictates the order of general
headings [General – Skin – HEENT
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

DOpalpation” 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
Handle acronyms appropriately:
o DrTahwestoanrgtehteaSuudbijeencctieveoaf
nydouOrbtjreacntisveal pitoorntiomnasytonroetabceh aa
D i hreeanlttihaclDarai egpnrooand
fdiarrhoea/constipation)
e sfiesdo
s(sD ioDassume
not n.)al. Expand
your target
o Be careful
acronyms of the order. Assessments should
(d/c =obvious signs/symbols (“R” for be written in the
will know even “Right).
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.

(P)LA
o Often a list, this should be well organised.
P al n
N
o Even th o ug h a b b re vi a t i o n s a re c o m m o n in p
m a y b e w r itt e n b y s y s e
t m d
/ si e a
rseesco
f rirptions, tracnosmlaptiloenxpcraostoecsoal
nshdomuludlaitvpoel idtLhaetrianp(iTeIsDf/foolro
l “twhr-euep.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.

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
Be sure to learn the acronyms, symbols and
2. Heasrthroartteh/paunldseassociated with your source
and
3. Respiratory ratleanguage combinations.
o It is also standard to record height, weight and BMI.
4. Blood pressure
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.

ACRONYMS/ABBREV.
o Identifying the type of acronym or abbreviation may help you in
the translation process.
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)
© 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 changeDso. n’t be afraid to double check!
Do they mean:
o Refer
to“HeaCrTlie2r5s0ecmtigon”sh( aynddr/oorchoirsttiosroynfeor2c5l0u
emso1.
.gP)r:Increase
“HCTZ 50 mg”
Novolin 70/30 (hydrochlorothiazide
to 22 units Q AM and 16 units 50
Q PM.
mg)? 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.
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
B e c a r e fu l w ti h p u n c t u a ti o n :
professionals a n d n o t p a tie n ts /c a r e t ak e r s !
Dashes (-), slashes (/), full stops (.), commas (,),
o Fact-baestce.dh; aavveoiddifflfoewreenryt
o Use clear and conciseal vnocgaubauglaersy., physicians are not
omreeamnbni egilsshni eddliafnegruenagt e.
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).

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
o Appropriate medical terminology should be used in SOAP notes.
o In English, this often means using the Latin cognate.
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
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 http://www.medilexicon.com
Abbreviations/Termino
l ogy
University of Michigan Plain Language http://www.lib.umich.edu

Dictionary
Tool Box for the Medical FR-EN/EN-FR Medical http://www.groupetraduction.c
Translator (FR/EN) Glossary &
Resources a/documents/ToolBox.pdf
Maxwell Quick Medical Doctor’s Quick Medical Amazon/bookseller
Reference Reference
Pocket medicine: The Pocket Handbook of Amazon/bookseller

Massachusetts General “Essentials”
Hospital Handbook of
Internal Medicine

QUESTIONS?

Thank
you
Erin M. Lyons
elyons@biomednouvel
e.com

Objectives: © Erin M. Lyons. ATA 2015, Miami

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SOAP Notes: Getting Down & Dirty With Medical Translation

To replicate the style and voice

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

“Patient presents for pain in the right upper quadrant (RUQ)”

© Erin M. Lyons. ATA 2015, Miami.

“Acute pain in the right lower quadrant (RLQ) on

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

ROS: WORDS &

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

 The structured system will provide you clues to narrow in on

 SOAP notes are universal: learn the preferred structure and

 SOAP notes are not written for patients, use appropriate

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

MEDICAL TERM LAY TERM

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

History includes narrative of patient’s complaints,

© Erin M. Lyons. ATA 2015, Miami.

Subjective section also includes social history,

© Erin M. Lyons. ATA 2015, Miami.

Physical exam and related laboratory

© Erin M. Lyons. ATA 2015, Miami.

Assessment is succinct; supported by prior

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

2. Avoid excessive use of acronyms or abbreviations; including

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

© Erin M. Lyons. ATA 2015, Miami.

University of Michigan Plain Language http://www.lib.umich.edu

Pocket medicine: The Pocket Handbook of Amazon/bookseller

© Erin M. Lyons. ATA 2015, Miami.

© Erin M. Lyons. ATA 2015, Miami.

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