I am a new, and need some help. after the doctor says plan he lists the medications he has prescribed. He does not number them and I am used to them saying medications and then listing (1, 2, 3) Do they usual do that? Should I leave it like he says it? Example:
PLAN:
Ecotrin 1 p.o. b.i.d. with meals. Keflex 500 mg p.o. q.i.d. for 4 days.. Follow-upl with me within the next 10 days.
That all depends on the QA person reviewing the report.
I have been told both are correct and both are wrong, other than if there is only one item (in which case you never number).
I have been audited and smacked down (points) for NOT numbering when the dictator did not number on meds and on diagnoses, etc., even on a verbatim account. I would love if someone could explain why. The client profile for the account says "do not number" if the dictator does not number.
I do not like to guess. Now it says for prostate cancer, so it might be. I will just flag it and put a s/l, just in case. I don't want them to think I didn't try to look it up either.
Here's another one: Under Assessment/Plan Subject: Here's another one: Under Assessment/Plan
1.Erythrocytosis – the patient did have a hemoglobin of 17 on blood work one year ago.I asked him to repeat it, but he forgot.We will recheck his CBC with NORRIS REPREEDIN level today and work this up accordingly.He is not symptomatic.
I keep listening over and over to this, and this is all I can make out. Any clue what he might be referring to??? TIA
If the doctor says assessment and plan together, do I put the header together? I am confused because when he gives the assessment he numbers them 1) 2) then when he gives the plan he numbers them as well but does not say plan any help?
ASSESSMENT:
Bilaterally arm numbness.
Nausea.
Health maintenance recommendations.
PLAN:
Patient’s critical examination was hyperreflexia suspicious for possible cervical lesion.She will be referred for MRI with cervical spine.Patient may need EMG to further access her numbness.
Patient will be tried on Nexium, although she does not have any overt symptoms of heartburn.She does have chronic nausea and this may be a sign of stomach reflux.She will be tried on Nexium 40 mg one q.d.Other diagnostic possibilities include slow gastric emptying. The patient does not eat breakfast or lunch and has her largest meal at about 8:00 at night.We discussed the need to consume breakfast and ideally eat 3-5 meals per day, smaller meals to encourage her metabolism.___ problem health maintenance and in regards to increase her exercise and changing her diet.Patient will be referred to OB/GYN for Pap and pelvic and also will be referred for a screening mammogram.When she follows up to see me we will discuss potential options for colon screening.Patient is to follow-up with me in approximately 1 month time.
I hate when docs do that - mine do it a lot. I think you're good either way but I would put "A&P" as the heading and then just type it the way the doc says it.
starts plan Subject: starts plan
it starts the plan then says ??? flonase 2 sprays each nostril
Sounds like a plan to me!! Subject: Sounds like a plan to me!!
Patient fell and injured right ankle. Sentence in question: She is significantly tender in the s/l coronal ligament s/l and the (or in the) right ankle.
Plan: MRI to rule out coronal ligament tear.
This is very clear - just cannot document it anywhere and don't want to flag it as it's very clear - just unsure and hoping for documentation or someone that has heard it.
Where would you begin the PLAN if the dictator does not say so? Subject: Where would you begin the PLAN if the dictator does not say so?
ASSESSMENT: We discussed options for Jeff. At this point, a month after the injury, an MRI, potential surgical interventions, etc., ultimately doing as well as he is, he is just going to keep it in mind and be careful with his lifting. He drives a forklift, apparently on a regular basis, but we are going to forego further work up at this point. We also got int a discussion of routine health care maintenance. He will plan on complete physical in October, starting this year. I will put a standing order at lab at this point for him, for a UA basic metabolic fasting lipid panel and PSA. We will go from there. Help with sentence. This is doc's treatment/plan: sm Subject: Help with sentence. This is doc's treatment/plan: sm
The sentence just doesn't seem right to me. Any input appreciated!
" Examination, evaluation, simple avulsion nail plate, 3rd left lateral aspect nail plate avulsed paronychium performed under anesthesia."
TREATMENT/PLAN: The plan would be to get an MRI scan of the pelvis and hips with intra-articular contrast of the right hip. One, we are going to try to rule out a stress fracture and two, we are going to try to rule out any pathology secondary to the possible cam impingement. I will see her back following the scan
Patient in for Plan B birth control. sm Subject: Patient in for Plan B birth control. sm
P: Pt is placed on oral bc. Discussed missed dose protocol. Reviewed ACHES (doc spells this out).
Hip joint arthroscopy is performed for femoral acetabular impingement, ...Cam lesions on the femoral head lead to shear forces of the nonspherical portion ... www.bryankellymd.com
Twenty-five years ago, SOAP format was still the in-thing, but doctors slowly trended away from it, probably due to medical transcription and formats changing over time. They are easy to do though. Recommendation and plan in patient with metastatic melanoma Subject: Recommendation and plan in patient with metastatic melanoma
To maintain DENSE intensity for neutropenic fever precautions, we have ordered Nuelasta 6 mg subcutaneous injection on 10/18.07.
For the life of me, I can't figure out dense intensity. Any ideas?
Thank you so much for clearing this up for me!!!! You are the best!
qestions about lesions.... Subject: qestions about lesions....
In the medial thigh there is a large protuberant mass 5 cm in diameter and 4 cm s/l PROUD of the skin, it is nontender. Thank you
OB..No lesions or s/l fi-a-bility is seen.. thanks Subject: OB..No lesions or s/l fi-a-bility is seen.. thanks
Patient has had a colonoscopy with a malignant polyp being found. Patient had a CT scan of her abdomen that showed multiple s/l lytic lesions throughout her bones everywhere.
Thx for any help!
OB... cervix is s/l perisome and without lesions.. thank you Subject: OB... cervix is s/l perisome and without lesions.. thank you
marks the location of current message within thread
I am a new, and need some help. after the doctor says plan he lists the medications he has prescribed. He does not number them and I am used to them saying medications and then listing (1, 2, 3) Do they usual do that? Should I leave it like he says it? Example: 
WHen doing a SOAP NOTE 
