Here's what I mean

Posted By: tf on 2006-06-30
In Reply to: Format for multiple problems - tf

Subject: Here's what I mean

Doctor says the patient comes in with two problems. says "First is her blah, blah, blah. Examination shows blah, blah, blah. Impression is blah, blah, blah. Treatment is blah, blah, blah.

Then he says "Her second problem involves her blah. Examinations shows blah, blah, blah continues with another full report like the first. Do I combine them or type history, physical exam, impression, and treatment twice?

There is no QA. I either have to call and ask them what to do (which I'd rather not) or do what I THINK is correct and wait for them to say "don't do that" which I would prefer. It is a one doctor office and these are just office notes.

Complete Discussion Below:

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Format for multiple problems - tf
- Here's what I mean - tf
  - Here's what I'd do. sm - nm
  - Since no QA, just do what you feel - FT MT
  - If QA has no recommendations, you don't have to have headings in there at all. Just do the report - as separate paragraphs for each prob. nm
- Best to ask your QA how the client prefers this to be done. nm - nm
- Can you see samples of how the other MTs handle it? Are these SOAP notes? Can you number the probs - under Assessment/Plan? nm
- Not sure what you mean. - FT MT

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