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4 SOAP notes, each w/ a cc-which one to pick?

  1. Default 4 SOAP notes, each w/ a cc-which one to pick?
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    I am trying to figure out what the CC is for an OV w/ 4 SOAP notes; so I can correctly assign the HPI, along with the correct CC. Anyone else seen that?

    Thank You!

  2. #2
    I'm not sure I understand your question correctly. The cc is usually pertinent to the visit. Do you have 4 notes by the same provider for the same visit?
    Karolina, CPC, CPMA, CEMC

  3. Default
    Thank you. Yes, I have four SOAP notes for the same patient from the same provider on the same day. Each one starts with"Patient presents for...", then the objective, assessment and plan for each one.

  4. #4
    North Carolina
    Gracious...Are you on an EMR? We're currently transitioning our multispecialty practice into an EMR and I have seen some unusual documentation. If you have 4, different, SOAP notes, with a variation of the CC...I would alert the MD and query he/she. But...I may not, still, understand the exact scenario you're providing.

  5. #5
    Default Gotta love the EMR glitches..
    I have a new provider that bought his own EMR, Praxis. There is quite a learning curve and there have been occasions when he has generated multiple notes for the same encounter. Each one has different information but nothing drastically different. It is obvious everything is related and just somehow on different notes. I just add the info together and level the visit.

    Example would be one note is just the MAs piece, next note is the MAs piece plus the HPI, the next note is the HPI plus the exam and MDM. He is signing all of them.

    Thankfully this has only happened a few times and is not really a reason I don't like Praxis, those are completely separate from this issue and have nothing to do with learning curves.

    Laura, CPC, CEMC

  6. Default
    Thank you. It is not , though, an EMR glitch. It is just the way the original provider has always done his notes which has lead to other providers doing the same thing. I try to add them together but am getting hung up on the CC since there are four separate problems with four separate A/Ps.

  7. #7
    This is a peculiar situation. What kind of provider? (I work in oncology and haven't really seen something like that.)
    Did the patient come in with several issues and a note was written for each problem? Then I would think you have multiple CCs - e.g., if someone came to the PCP for follow-up on diabetes, asthma, hypertension and a rash. I would imagine that all diags get attention and all would be documented, but I'd find it hard to imagine that each problem gets a separate note.
    Is that the case with your situation?
    Anyway, basically all documentation for the same DOS by the same provider needs to be taken into consideration for one visit on the day.
    The primary cc for the day should be the one that was the cause for the visit, so if the patient came in because s/he was wheezing and the asthma was addressed first and foremost and then the doc alse checked on the rest of the issues, I would go with asthma as cc (that just an example).
    Not sure if this is helpful...
    Karolina, CPC, CPMA, CEMC

  8. Default
    Thank you. Yes, each problem gets its own SOAP note which leads to the first problem, perhaps, not having any ROS elements but the second one does, etc. I agree that the first problem s/b the CC but then don't you have to count the HPI elements of the first problem and not the next three? What is throwing me is the fact that each problem has its own SOAP note.

  9. #9
    Columbia, MO
    Your physician has always documented this way? Or has someone recently indicated this is the way to get higher levels? I just have never experienced a physician that documents like that. What does he feel is the advantage to this , because it seems like a lot more work on his part. As far as your coding, my opinion would be to use the more severe or acute dx as the first listed and not duplicate any elements of each note for the visit level, such as the ROS or HPI elements. I think that is the best you can do.

    Debra A. Mitchell, MSPH, CPC-H

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