I need help coding this SOAP note. I am not real familiar with these and I cant not find a good auditing tool for these notes. Can someone please help me code this and maybe explain how they did it? I have to use 1995 auditing guidelines as well.
hospital: Daily progress note
S: pt doing well, was vey SOB today going to bathroom, 0emesis, 02 sats to 82% on RA. some cough, taking good PO.
O: VSS afebrile
CV:RRR, 0 mumur
Resp: Bibasilar rales, 0 rhonchi
GI: bowel sounds+, nontender
EXT: 0 edema
A/P 1) Ileus better, continue PO
2) CHF noted, IV INT, give Lasix
Re BMP in a.m., CXR, HGB
hospital: Daily progress note
S: pt doing well, was vey SOB today going to bathroom, 0emesis, 02 sats to 82% on RA. some cough, taking good PO.
O: VSS afebrile
CV:RRR, 0 mumur
Resp: Bibasilar rales, 0 rhonchi
GI: bowel sounds+, nontender
EXT: 0 edema
A/P 1) Ileus better, continue PO
2) CHF noted, IV INT, give Lasix
Re BMP in a.m., CXR, HGB