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emr:soap [2023/10/30 14:05] – admin | emr:soap [2023/11/09 21:11] (current) – admin | ||
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- | __**Assessment / Plan**__ | + | ==== SOAP ==== |
+ | [[secret]] | ||
- | **Billing Details** | + | ==== E/M billing ==== |
- | + | * [[https:// | |
- | **Subjective** | + | * [[https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf | 2023, AMA outline]] |
- | - overnight, no acute events | + | |
- | - reports no specific concerns | + | |
- | + | ||
- | Full ROS performed. Negative except as mentioned above. | + | |
- | + | ||
- | **Objective** | + | |
- | //Vitals// | + | |
- | Tmax x | + | |
- | + | ||
- | //Exam// | + | |
- | RRR.CTAB | + | |
- | + | ||
- | //Labs & Imaging// | + | |
- | + | ||
- | All labs and imaging within past 24 hr personally reviewed by me. | + |