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emr:soap
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Table of Contents
SOAP
Assessment / Plan
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
emr/soap.1698678557.txt.gz · Last modified: 2023/10/30 15:09 by admin
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