Forum - Questions & Answers
soap note format
When the doctor is using the soap method to note o/v where do the assessments generate from? The subjective? the ROS? the procedure?
i/e.
S- pt here for purpura and fatigue
O- skin: patches found on right forearm, upper arm; plantar wart on left foot
general: pt complains of fatigue x 2 weeks
heent: all clear
P obtain CBC, continue medication for purpura
A diagnoses: purpura
fatigue
plantar wart
Notice there is a problem listed in the objective but it was not addressed in the subjective.
We'd appreciate the input.
Not sure the question...
you can take data from any part documented by the doctor to count ROS, assessment, plan. It is clear that fatigue is a subjective not objective. You can count it as a complaint
in a perfect world....
All problems addressed at the visit would be in the A/P part of the note. I would use the note as an educational opportunity and ask the physician to list the problems addressed in the assessment. But, you can take diagnosis codes from the entire note.
Is that the question?