Medical Transcription: Chart and Progress Notes - dummies

Medical Transcription: Chart and Progress Notes

By Anne Martinez

One kind of report you will see in medical transcription is a chart note. A chart note, also called a progress note or office note, is dictated when an established patient is seen for a repeat visit. A chart note records the reason for the current visit, an assessment of the patient’s condition (including any changes since the previous visit), and additional treatment rendered or planned.

A chart note may be as short as a few lines, especially for a follow-up visit. A new problem may warrant several paragraphs.

Because chart notes are often so short, some offices will have you transcribe multiple notes into a single document. They’ll be split apart later after the physician has reviewed them. They can be dictated in a variety of formats, including

  • Like a mini H&P, with similar headings but less depth

  • As a single paragraph (often just a few sentences)

  • Using SOAP note format or a close variation (most common)

SOAP is an acronym for:

  • Subjective: The reason the patient is being seen, including description of symptoms provided by the patient or other individuals.

  • Objective: Details drawn from the provider’s examination of the patient’s condition, including lab data.

  • Assessment: What the provider thinks is wrong with the patient, based on subjective and objective details.

  • Plan: What the provider recommends be done regarding the patient’s condition. This may include obtaining lab work, referral to a specialist, or ongoing treatment and follow-up details.

Given their love of shortcuts and acronyms, it should come as no surprise that some dictators just say the letters S, O, A, and P instead of the full headings.

Some dictators use a different set of abbreviations to accomplish the same thing:

  • CC: An acronym for chief complaint, equivalent to subjective

  • PX or PE: Shorthand for physical examination, equivalent to objective

  • DX: Abbreviation for diagnosis, equivalent to assessment

  • RX: Abbreviation for prescription, in this case prescribed treatment plan

A dictator may omit sections or mix and match headings. For example, he may dictate Chief Complaint in place of or in addition to Subjective but otherwise follow the SOAP acronym. He may inject additional headings, such as Lab Data or ROS (Review of Systems) along the way. You should transcribe whichever headings are dictated unless you’ve been specifically instructed otherwise.

In addition to the patient’s reason for seeking care, the subjective heading often incorporates background data, creating a mini history, like this:

SUBJECTIVE: He is here for evaluation of back pain. He has had persistent back pain which was somewhat improved by PT but has been severe and disabling. He cannot walk or bend over very well, but he is slowly improving. He is taking Flexeril and Vicodin.

In fitting with the condensed nature of chart notes, most facilities format chart notes with the text starting on the same line as the heading. It’s also common to indent the text from the heading, like this:

S:    A 90-year-old here for a follow-up on her medical issues, which include atrial fibrillation and valvular heart disease.

The Objective section may be just a sentence or two about the relevant body part, like this:

OBJECTIVE: She does have some swelling around the anterior ankle.

Or reference another document:

OBJECTIVE: See labs.

It may be replete with jargon, abbreviations, and acronyms to jam a physical exam into as small a space as possible, which you should transcribe as dictated:

O:    Lungs clear. Cor nl. S1, S2, neg. S3, S4, murmur. Abdomen neg. h/s meg., masses, tenderness. Ext’s no edema.

In a dictation like the preceding one, the only way you’re going to have a fighting chance of understanding the dictator is to refer to her previous reports.

The Assessment and Plan sections may be separate or combined. There’s no need to number multiple diagnoses unless the dictator does. Nor do you need to expand diagnoses acronyms in SOAP notes, even though you would in most other report types:

A:    DM type 2. Depression, improved.

P:    Reviewed glucometer usage. Reviewed his diet.

A combined Assessment/Plan section would resemble this:

A/P:    Atrial fibrillation: Stable. Good rate control. Continue anticoagulation at this time.

Pneumonia: Improving on Zithromax day 3/5.