need help with SOAP note

KristyJ

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Help with a SOAP note, (daily progress note) using 1995 guidelines, hospital visit.
S: Pt doing well, was very SOB today going to bathroom, 0 emesis, O2 sats down to 82% on RA, some cough, taking good PO.

O: VSS Afebrile
CV: RRR, 0 murmur
Resp: Bibasilar rales, 0 rhonchi
GI: bowel sounds +, nontender
Ext: 0 edema

A/P 1) ileus better, continue PO
2) CHF noted, IV thru INT, give lasix,

Re, check BMP in am, CXR, HGB
 

jsalzer50

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Subsequent Hospital Care E/M

Hey Kristy:

I appreciate you asking this and sharing this SOAP note. As a coding student, it helps me two-fold (1) first, I will translate this report into English, and (2) will do my best to code this using my skills in E/M.

A SOAP progress note at a hospital (in my mind) = subsequent hospital care.

I'm getting an expanded problem-focused history, expanded problem-focused exam, and moderate MDM.

To the best of my knowledge, I would use E/M code: 99232

But if time was documented, then we would use time to select the E/M code.

- Jacob


Here is my attempt to breakdown the abbreviations:

S: (subjective) Pt (patient) doing well, was very SOB (shortness of breath) today going to bathroom, 0 emesis (no vomiting), O2 sats (saturations) down to 82% on RA (respiration), some cough, taking good PO (per oral or by mouth).

O (objective): VSS (Vital Signs Stable) Afebrile (no fever)
CV (Cardiovascular): RRR (regular rate and rhythm), 0 murmur
Resp (Respirations): Bibasilar rales, (abnormal rattling sounds) 0 rhonchi
GI (Genitourinary): bowel sounds +, nontender
Ext (Extremities): 0 edema

A/P (Assessment and Plan)
1) ileus better, continue PO (by mouth)
2) CHF (congestive heart failure) noted, IV thru INT (intermittent needle therapy), give lasix,

Re, check BMP (basic metabolic panel) in am, CXR (chest xray), HGB (hemoglobin)
 
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