Differences

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--- emr:soap [2023/10/30 14:07] – admin
+++ emr:soap [2023/11/09 21:11] (current) – admin
@@ Line 1: / Line 1: @@
-__**Assessment / Plan**__
+==== SOAP ====
-M with history of x, initially admitted for X, now with x.
+[[secret]]
-Acute hypoxemic respiratory failure
+==== E/M billing ====
-Septic shock from GNR bacteremia
+  * [[https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf | 2023, CMS outline]]
-Acute kidney injury, grade 2
+  * [[https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf | 2023, AMA outline]]
-__Recommendations__
-- XX
-- xxx
-**Billing Details**
-**Subjective**
-- 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.

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