Wiki soap notes help

perkins05

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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?
 
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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