EM level

asasands

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If our dr does his consult in the SOAP format how do I code:

Under S: Severe abd pain. Not able to eau due to pain with n/v. On clear liquid diet as well as tube feedings. Slight pain due to vomiting. Urination without issue. No BM. No CP. 40 wt loss. Not on any antibx.

Under O: Lipas 245, CA 7.9. Ast level, a/k phos 648 HEENT HEAT LUNG ABD EXT and radiology all reviewed.

Under A/P Pancreatitis, possible abd abscess.

Pancreatitis psuedo cyst and malnutrition, and reflux esophagitis.

What would you code?

Stacey
 
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