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
Duration Radiation
Temporal pattern
Severity

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.

by Jonathan Hine

We who serve as bridges between cultures know that travel enriches our work as much as our lives. Indeed, it nourishes our very souls. For most, traveling involves breaking away and coming back. However, as professionals working in the 21st Century, we don’t have to make travel an exception to our “normal” life. Working while traveling may be easier and more effective than you expect– whether your ticket is one-way or round-trip.

By way of background, I have been living and working on my bicycle since leaving Charlottesville, Virginia in September 2013. Since then, I have made many changes, as I got rid of things that I was not using, learned to use the smartphone, the internet and the cloud more efficiently, and changed continents from North America (2013-2014) to Europe (2015-).
The details are in my blog(http://freewheelingfreelancer.com).

A miscellany of thoughts.
If you are going to keep working while traveling extensively, you will need a computer that will support your business on the road. It needs to be capable of handling all the software and applications that you need, but not be too big for the travel mode you are using. If you are traveling in a car, you can haul a desktop around; on my bicycle I can’t use anything bigger than a 13-inch laptop or tablet with a keyboard. My current workhorse is a Microsoft Surface 3. Its little sidekick is a Nexus 5 Android smartphone.

Over the last three years I have learned to exist almost completely without paper. All the paper documents that I used to carry around in files and briefcases are now in PDFs, located on my telephone, in my computer, and on a 1 TB hard drive that I keep separate from the computer. The smartphone instantly converts new papers and documents into PDFs for the collection. I have been able to find a printer whenever I needed one, either in the business center of a hotel, a public library, an office store like FedEx or UPS, or at friends’ homes.

For revising translations, I prefer two sheets of paper side-by-side. That becomes challenging on the road, so I have found an HDMI cable very helpful, plugging my computer into the large screen TV found in many hotel rooms. That allows me to put up full-size (or enlarged) images of two documents side-by-side. Let me be clear that it is not as good as paper, but it works.

Each of us has to find our own way to maintain a routine. That can be difficult, if you are working for other people and having to interact with them, especially across time zones. If you are traveling slowly, at least you can avoid jet lag. When I know that I am going to fly somewhere west of where I am (e.g., an ATA Conference from Europe), I try to go to bed later and get up later every day for a week, until I am essentially functioning on local time for the destination. Even when I am in Europe for months at a time, I work as late as I can and sleep in, because most of my clients are on US Eastern Time.
Besides the road itself (don’t text), sleeping and exercise are the two most important things you can pay attention to while living on the road. If your traveling is your exercise, like my bicycle, you have it made. If not, then you have to make time for running or walking, workouts in the hotel gym, or whatever will keep you fit and ready to work. Remember that sleeping is as important as exercise, because you cannot be fit unless you recover from the exercise properly.

If you don’t have medical insurance, get it. If you’re traveling outside your home country, travelers’ insurance is a good deal unless you are over 65. It takes the headache out of wondering what would happen if you get sick or injured on the road.
Potentially, one of the nice things about the nomadic lifestyle is financial flexibility. When I was living in one place, I found that overruns in one part of the budget could not be compensated for somewhere else. I could not trim the mortgage or the car payment to handle a surprise in the electric bill. On the road, I have found that eating cheap can make up for having to spend too much for the hotel room and vice versa. Since leaving Charlottesville, I have yet to run over my budget or fail to pay the balance on my credit cards in any one month (not counting the month I completely forgot, but the money was there!).

It took two years (2011-2013) to get ready to do this. Part of that was taking a very hard look at the budget, and building up my savings account before I started out. Once I started traveling, I found that the freelance income paid for the itinerant lifestyle without having to dip into savings. But I might have stressed out and made some bad business decisions had I not put that safety net in place.

If you are remaining in North America, you probably don’t have to change your checking accounts, your business mailing address and things like that. If you decide to travel abroad, as I am doing now, you have to be very clear about a few things. One is to remember that you are not your business. I believe in keeping a single location for the business, both physically and legally. For example, Scriptor Services LLC is in Charlottesville Virginia and has never moved. The company pays its business taxes and renews its business license there every year. It pays a business support consultant to check the PO Box, and either she or my son forwards the mail on a regular basis to wherever I am. She also deposits checks from those few clients who have not left the twentieth century. All of my banking is online with my credit union. Because all of my work is online, through email and the Internet, the estimates, invoices, payments, etc. all move to and from the Charlottesville location. I have found no need for a European bank account or credit cards for business or personal affairs. This is just as well, because the Financial Accounting Transaction Control Act (FATCA) is creating a nightmare for middle class Americans traveling or living overseas. The exchange rates on my credit card transactions are just a cost of living overseas. Of course, if you are going overseas, be sure that the cards that you carry are chip-and-PIN cards (EVM in Europe), and that they don’t charge foreign transaction fees.

Alone and in (good) company
Working on the road can happen anytime. Some take work to professional conferences or high school reunions; others tap on their laptops in airport lobbies or on the train. I did that for five decades myself. Based on what I’ve learned traveling alone, with a friend, and with a family, I suggest that you need to be clear in your own mind about whether you are on a vacation or traveling while you work. If you have someone with you, the decision to work on the road has to be shared. For example, when I ride by myself, I go about half as far each day as I do when I’m riding with my friend in the summer. This is so that each day, I have time to process my email and work on whatever translation is due next. When alone, I can accept a rush job that requires me to stay put for a couple of days and crank it out. I make that decision on the spot, as I prepare the estimate for the client. One consideration is, “Will this job pay for the place that I am having to stay in now?” It almost always does, and I try to stay in places with internet, even campgrounds. The other consideration is, “Can I afford to stop and still get to where I am headed?” If I have to make a flight from Fiumicino or Heathrow next week, I may not have the option to stop.

Each summer, I go on holiday. At that point, I don’t even try to take in new work. Instead, I concentrate on touring each day, seeing the new marvels and sites that we will visit, and writing it all up for my blog. Personally, I have not yet found a balance that allows me to get a reliable amount of work done each day while touring long daily distances.

If “family” consists of only yourself and your partner, then the analogy is similar to touring with a friend. If you both have to make a living, you can share the decision to travel a little less each day, or to stop frequently to work. If you’re traveling by car, RV, plane, boat, or something with more than two wheels, one of you can work while the other is piloting the vehicle.

Traveling and working with children is another story. However, there are far too many examples of successful families living on the road for one to say that it cannot be done. With children, it definitely helps to have a partner if you are trying to work while traveling. If both must work, then you have to take turns with the kids. Children need and deserve the attention that they demand, and the one parent who is working needs the support of the other to keep it all running together smoothly. Children are remarkably adaptable, and as they grow, they are capable of doing more and more to help the family unit moves along.

When they reach school age, you have to decide whether you are going to travel only during the holidays, or home school. I have met several families who made the latter decision, but in each case, one of the two parents was already a schoolteacher. That is not usually a requirement; in Italy and in many American school districts, it is simply necessary that one of the parents have a college degree. I have met families who lived on the road using bicycles, automobiles, recreational vehicles, sailing vessels, trucks, public transit, and even a Chinese junk.
Of course, if you make the summer vacation decision, it becomes easier, because you and the children can concentrate on the traveling, with or without your having a partner. As a freelancer, you have the make all your money during the school year, but so do school teachers, college professors, and ski instructors. It can be done. The friend with whom I tour in the summer took her two-month old son to Europe rather than interrupt her planned trip. They rode the rails until he was four. He grew up knowing that summers were spent on a bicycle with mom. The summer that I met her, he had a job in California. It was her first tour without him since he was born. I have met him, and he is a very impressive and well-adjusted young man.

Final thought
Here is a tip from a former boss of mine, Admiral Gerry Miller of the US Sixth Fleet:

If you are not having fun, you are not doing it right!

This means fun in the broader sense of “satisfaction”, not just always happy. If I am not enjoying my work, it’s time to take a look at the work itself or the way I am going about it. It’s also a signal that I need to ask around. The same thing applies to your travel and to working on the road. Be prepared to change, but don’t give up too quickly. Buon viaggio e buon lavoro!

Reprinted with gracious permission from The Savvy Newcomer and permission from the author.

As a new ATA member in 2015, I received my first edition of The Chronicle and was intrigued by the article about Jenny Stillo, the winner of the 2013–2014 School Outreach Contest. At the time, I was in my sixth year working for the Spanish Ministry of Education as a cultural ambassador, which involved visiting students of English in public schools across Spain. The combination of the chance to win a free registration to the conference in Miami and the opportunity to teach students about my passion and (at the time) part-time job was what inspired me to participate in the program.

My Preparation Process and Presentation

I started by checking out the resources provided on the School Outreach Program’s website (http://www.atanet.org/ata_school/) to see the content of past participants’ presentations and how they made themselves stand out with their winning pictures.

I then decided to make my own presentation from scratch. I started by introducing what interpretation and translation are, who linguists work for (agencies, direct clients, the UN), and what they specialize in. I also touched on life-changing “translation fails,” for example a boy who tragically became a paraplegic due to the misinterpretation of a medical term and an international bank that lost millions. I ended the session with two interactive activities. (You can check out my presentation on the School Outreach website: www.atanet.org/ata_school/level_middle.php.)

The first activity was based on a very real-life situation for these kids. Language students all over the world love to use Google Translate to do their homework, and I wanted to show them that they could do a better job than their computers could. I started by showing them a picture of a mistranslation, a sign that said “Exit Only” in English and “Éxito Aquí” in Spanish (“Success Here” in English) — they all laughed and wondered how anyone could ever translate so poorly. I then asked them if they thought Google Translate could do a better job… and the majority of them thought it could. I showed them that Google’s translation of “Exit Only” was “Única Salida” (“Only Exit” in English), and they decided that although it is not perfect, it worked better than the original translation. I followed this same process with a number of funny photos. The last step of this activity was asking them to come up with their own, correct translation for each less-than-perfect one. I have to say that they did a fabulous job. At first they made the common mistake of translating too literally, but they quickly got the hang of it. I think they were pleasantly surprised that they, 13-year-old English-language learners, could write better in English than the all-powerful Google.

The second activity was what brought about the winning photo. This class had a particularly large number of immigrant students from around the world and I had each of them translate “My name is…” into their native language on a colorful, comic-book-style speech bubble. In the photo you can see Russian, Arabic, French, Romanian, Spanish, Asturian (the local dialect), and English (that would be me). I had all the kids pose and hold their speech bubble up to their mouth, making for a happy and bright picture. The most rewarding part was that there were three students who didn’t know how to write in their mother tongue. That night, they asked their parents how to write out the sentence and were excited to show off their native languages in class the next day. One boy even brought in the entire Arabic alphabet copied by hand and spent the next school day writing all his friend’s names from right to left. Everyone was impressed, he was proud, and I was so happy to see it.

The culmination of it all happened right as I was walking out the door. One student came up to me, tapped me on the shoulder, and confessed: “Molly, I’m definitely going to think about becoming a translator.” Success!

Why participate in the School Outreach Program and Contest?

Let’s be honest: lots of kids dislike their language classes, and I think it’s because they think they’re useless. Kids don’t see or hear much about other languages in their daily lives, especially in America. Making an entertaining, interactive presentation where they can see the consequences of mistranslations, a possible career for their future, and the fun in it all, is extremely rewarding. Through this program, we can change the way they think about language and make them see that it isn’t just another subject in school — that language is a powerful tool that is becoming more and more important every day.

The other benefit to participating is monetary. If you win the photography contest, you get a free registration to next year’s conference! Not only that, but it really gets your name out there and you get to meet a lot of great people along the way. From my point of view, it’s all benefits. I even had the nice surprise of having my photo on the cover of The Chronicle.

Recycling my Presentation

I had such a great experience that I decided to repeat my presentation when I was home in Minnesota for a visit this winter. I talked with a classroom of adult ESL students in the Adult Academic Program in my local school district.

The experience was an absolute blast! The classroom was filled with immigrants and refugees from all over the world and they were so interactive and excited to have me there. They were mostly surprised to learn the difference between translation/interpreting and asked tons of questions (How much can you make? What if you make a big mistake? How can we study? Who can we work for?). At the end, I opened it up for discussion and many of the students told me stories about their bad experiences with interpreters. One man shared that he volunteered when he was at the doctor’s office and could see there were Spanish-speaking patients waiting for their interpreter, who never showed up. He said he volunteered for five hours to help people communicate with their doctor.

Throughout the presentation, I encouraged all of them to continue with their English studies to work towards a career in interpreting. You should have seen their faces! I think that for many immigrants and refugees, a “real job” seems out of reach. They looked so entirely hopeful that they could make a career for themselves in this field while helping their fellow community members at the same time.

I encourage you to educate others about our great field by participating in the School Outreach Program. Whether you visit a classroom of children or adults, you will quickly see how rewarding the experience can be. If you’re interested in participating in the photography contest, you must submit a photo and description of your presentation by the deadline on July 18, 2016.

About the author: Molly Yurick is a Spanish to English translator specialized in the tourism, hospitality and airline industries. In the past she has worked as a medical interpreter in Minnesota and as a cultural ambassador for the Ministry of Education in Spain. She has a B.A. in Spanish and Global Studies and a Certificate in Medical Interpreting from the University of Minnesota. She is currently living in northern Spain. You can visit her website at: http://yuricktranslations.com