User Tools
emr:soap
Differences
This shows you the differences between two versions of the page.
| Both sides previous revisionPrevious revisionNext revision | Previous revision | ||
| emr:soap [2023/10/30 14:58] – admin | emr:soap [2023/11/09 21:11] (current) – admin | ||
|---|---|---|---|
| Line 1: | Line 1: | ||
| - | __**Assessment / Plan**__ | + | ==== SOAP ==== |
| + | [[secret]] | ||
| - | 65M with history of x, initially admitted for X, now with x. | + | ==== E/M billing ==== |
| - | + | * [[https:// | |
| - | Acute hypoxemic respiratory failure | + | * [[https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf | 2023, AMA outline]] |
| - | + | ||
| - | Septic shock from GNR bacteremia | + | |
| - | + | ||
| - | Acute kidney injury, grade 2 | + | |
| - | + | ||
| - | __Recommendations__ | + | |
| - | + | ||
| - | - XX | + | |
| - | + | ||
| - | - xxx | + | |
| - | + | ||
| - | **Billing Details** | + | |
| - | + | ||
| - | |Problems|1, | + | |
| - | |Data|xx| | + | |
| - | |Risk|xx| | + | |
| - | + | ||
| - | **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. | + | |
emr/soap.1698677935.txt.gz · Last modified: 2023/10/30 14:58 by admin
Except where otherwise noted, content on this wiki is licensed under the following license: CC Attribution-Share Alike 4.0 International
