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emr:soap [2023/10/30 15:09] – adminemr:soap [2023/11/09 21:11] (current) – admin
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 ==== SOAP ==== ==== SOAP ====
-__**Assessment / Plan**__ +[[secret]]
- +
-65M with history of x, initially admitted for X, now with x. +
- +
-Acute hypoxemic respiratory failure +
- +
-Septic shock from GNR bacteremia +
- +
-Acute kidney injury, grade 2 +
- +
-__Recommendations__ +
- +
-- XX +
- +
-- xxx +
- +
-**Billing Details** +
- +
-Problems: 1,2,3 +
- +
-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.+
  
 ==== E/M billing ==== ==== E/M billing ====
 +  * [[https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf | 2023, CMS outline]]
 +  * [[https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf | 2023, AMA outline]]
emr/soap.1698678557.txt.gz · Last modified: 2023/10/30 15:09 by admin

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