Medical Transcription Services Company

Here is the scenario. The patient, Jane Doe, A–1 history–physical, was admitted to the hospital, received treatment and has now returned to the doctor's office for followup, generally made as a return appointment at the time of the first visit, and roughly near the time the care provider dictated the history-physical.

Subjective (what the patient thinks) = S
Objective (what the doctor thinks) = O
Assessment (what the diagnosis is) = A
Plan (what happens next) = P

Not all providers dictate the "SOAP" note format; sometimes they simply state in a narrative way the same information. In that case, you would just leave out the abbreviated headings on if the client prefers, the headings, Subjective, Objective, Assessment and Plan information may be defined (with some practice) so that the transcriptionist organizes the appropriate data under the headings where it belongs.

In both the history-physical and in the chart note, when instructions for medications are given, the following table lists the abbreviations and its meanings:

	Abbreviation	Meaning
	p.o.	per oral (or by mouth)
	n.p.o.	nothing per oral
	b.i.d.	twice a day
	p.r.n.	pro re nata (as needed)
	q.a.m.	every morning
	q.p.m.	every evening
	PX	prescription
	RX	(or Rx) prescription

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