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
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