Assessment & Plan Elements
Loading Add to Favorites
Share
Tweet
Cite
[comment memo="coding blurbs" memo_size="small"][checkbox value="-The above SocHx/Allergies/Meds/PMHx/PSHx/FMHx were reviewed & updated at today's visit.
"][checkbox value="-The scribe/medic/nurse/student assisted in collecting and documenting the patient's history.
-I have personally reviewed it and verified its accuracy.
"][checkbox value="-The scribe/medic/nurse/student assisted in documenting the physical exam performed by me.
-I have personally reviewed it and verified its accuracy.
"][checkbox value="-Laboratory results as displayed were reviewed and interpreted
"][checkbox value="-Radiologic study results as displayed were reviewed and interpreted
"][checkbox value="-Radiologic study images which results are displayed in note were reviewed and interpreted
"][checkbox value="-Pap smear was performed and sample collected at today's visit, sample to be sent to lab for analysis
"]A/P:
[checkbox name="apMigraine" value="HA/Migraines:
"][checkbox name="apChronicRhinitis" value="#CHRONIC RHINITIS:
"][checkbox name="apAsthma" value="#ASTHMA
"][checkbox name="apCOPD" value="#COPD:
"][checkbox name="apILD" value="#ILD/PULM FIBROSIS:
"][checkbox name="apCVDMI" value="#CV DISEASE:
"][checkbox name="apCHF" value="#CHF:
"][checkbox name="apIBS" value="#IBS:
"][checkbox name="apGERD" value="#GERD:
"][checkbox name="apPUD" value="#PEPTIC ULCER DISEASE:
"][checkbox name="apConstipation" value="#CHRONIC CONSTIPATION:
"][checkbox name="apIBD" value="#INFLAMMATORY BOWEL DISEASE:
"][checkbox name="apDJD" value="#DEGENERATIVE JOINT DISEASE:
"][checkbox name="apDJD" value="#DEGENERATIVE DISC DISEASE:
"]
coding blurbs A/P:

Result - Copy and paste this output:

Send Feedback for this SOAPnote

More SOAPnotes by this Author: