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by Erin Lyons
Progress notes and patient records are the medical translator’s bread and butter; however, this does not prevent even the most seasoned medical translators from getting burnt. While most medical translators are experienced in translating these documents, a failure to fully understand the nuances of their structure, language and rationale limits translators’ ability to replicate the style and voice of healthcare practitioners. Furthermore, this puts up roadblocks when attempting to decipher strings of murky acronyms and seemingly unintelligible scribbles. 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), based on the context, and how this linear format can point translators to the right bodily system or examination, regardless of seemingly impenetrable and opaque source language.
Clearly, when we speak about SOAP notes we are not talking about something you wash up 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 healthcare providers to communicate and provide evidence of patient contact. While the style and content may vary slightly based on the medical specialty or healthcare center, the Subjective – Objective – Assessment – Plan structure remains unchanged during the charting process.
The SOAP note format starts with the subjective component. This section is considered “subjective,” since it is based on the patient interview 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 this may seem straightforward enough, this section can often be murky and truncated, particularly when a patient has a long, complicated and/or known history and the translator may have only been given an excerpt of the medical record. In such cases, it is helpful to know what information physicians and nurses are looking for when gathering and compiling information regarding the patient’s CC. The classic “OLD C(H)ARTS” medical school mnemonic device is particularly useful for translators as well:
Onset Character (sharp, dull, etc.)
Location Alleviating/Aggravating factors
Understanding that healthcare practitioners are seeking to record these seven 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. Healthcare 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 observations, although other tenses may be necessary to show a chronology of events. Furthermore, it is good practice to expand acronyms for first use (i.e. PID should be written “PID [pelvic inflammatory disease]” and “PID” can subsequently be used without expansion). Additionally, when translating acronyms, translators should be wary not to directly translate acronyms, 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 and while, in theory, this should be understood, in 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.
As opposed to the subjective section, the objective section 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, which dictates the general order of subheadings and generally literally moves from head to toe. It is important to remember this order of the review of systems (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 for cardiovascular, but a symbol that might be less clear is two triangles for lungs/pulmonary. The World Health Organization ICD-10 codes (http://apps.who.int/classifications/icd10/browse/2016/en) is 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. Merely entering a general term, such as “pulmonary” in the search box will generate a complete list of pulmonary-related diseases, their code 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 a burn exam, motor vehicle accident history, cardiac risk and TIMI risk score, etc. These templates are invaluable for both experienced and novice medical translators, as they are framed for physicians, helping translators generate more authentic and transparent translations.
The third section is the assessment, which 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 previously gathered. This is generally is written in descending order of severity and may also include hypothetical language when referring to possible or likely etiologies of the disease. Translators should take care in this section with the modal verbs used (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 is vital that the translator remain as faithful to the source language as possible in terms of degrees (very, slightly, mild, severe) and that a correct doctor-facing register is employed. 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 (https://labtestsonline.org/map/gindex). This resource provides a glossary and cross-references for tests and results by symptom, condition and screening panel.
The final section of the SOP note, the plan, 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, monitoring, etc. 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. Again, 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, 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; the use of “TID” for “three times daily” or “h.s.” for “at bedtime” may be commonly used; however, often times SOAP notes may be reviewed by non-medical professionals, as part of clinical trial adverse event reporting or insurance claims, so it is good 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.
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 is 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 called for 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 towards accurate and fact-based translations that read like a professional document and not like a translation.
Erin M. Lyons is a French and Italian to English translator, medical writer and consultant and the Owner of BiomedNouvelle. She is also an Adjunct Professor of Translation at the University of Maryland. Her primary areas of focus include clinical research, medical devices, and cosmetic products, as well as developing BabelNouvelle®, a mobile-based translation technology to facilitate medical services in the developing world. Ms. Lyons holds a BA from the University of Chicago and an MA in Translation from MIIS.