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soap notes help

  1. #1
    Exclamation soap notes help
    Medical Coding Books
    cc uri

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


    Health maintenance; reviewed flu shot 09 mamogram 09


    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?

  2. #2
    Milwaukee WI
    Default 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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