soap notes help

perkins05

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Location
New Orleans
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sample
cc uri

pt cough nasal drip one week unable to sleep use nasal spray some relief

ros:

Health maintenance; reviewed flu shot 09 mamogram 09

objective:vitals,bp

exam; general
head eyes ears lungs heart abodmen

plan; review meds
dep shot


Help needed : Are all compoments needed to level?
If nothing listed under ROS can it be pulled from another section?
 
Messages
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Location
Milwaukee WI
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Take ROS from HPI

You want to try to get some ROS.

You can take "cough, nasal drip" and "unable to sleep" from the HPI and use that for a "problem pertinent" ROS.
You would still have duration (one week) and modifying factors (nasal spray with some relief) for HPI.

This gives you an EPF history

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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