SOAP

thomas7331

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SOAP is just a format that some providers use for documenting their encounters. It does not change how you code - you should still code the encounter based on the content of the documentation, not the format. Typically, the S/subjective has the history, O/objective has the exam, and the AP/Assessment & Plan contains the MDM, but not always since providers may sometimes put information under the wrong header.
 

Pathos

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I agree with Thomas. The SOAP format is merely the framework of most chart notes, but it is not a requirement. As long as documentation supports the E/M components required to bill an E/M level, it really doesn't matter how the chart is setup. I have audited providers who documented their E/M note in one big paragraph, and could still extract a full History, Exam and MDM out of it. Always keep in mind to never "double dip", and you should do fine.
 
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