assessment&plan help!
Posted By: rach on 2006-11-21
In Reply to:
Subject: assessment&plan help!
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.
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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
assessment and plan
Subject: assessment and plan
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.
Subjective, Objective, Assessment, Plan=SOAP..
Subject: Subjective, Objective, Assessment, Plan=SOAP..
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. 
Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?
Subject: Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?
Sorry, tried to help. Have a nice weekend.
Assessment
Subject: Assessment
ASSESSMENT: Family history of AAA. Will proceed with -- s/l "root" ----- to evaluate.
Anyone have any idea what this is?? I'm drawing a blank.
TY!!
Help with assessment
Subject: Help with assessment
Hypertension with s/l "realciaporosis"...??
Any ideas??
TIA
assessment ?
Subject: assessment ?
Patient had an s/l EIP - EPL transfer.
in the assessment i would, otherwise no
Subject: in the assessment i would, otherwise no
Assessment ?
Subject: Assessment ?
Assessment ?
Subject: Assessment ?
Can you have an abbreviation like URI in an assessment? Thx. Tina
Assessment
Subject: Assessment
Thank you for the assessment info!!
CAGE assessment?
Subject: CAGE assessment?
CAGE Assessment (Alcohol Abuse)
Powered by:. CAGE Assessment (Alcohol Abuse). For most people who drink, alcohol
is a pleasant addition to eating and to other social activities. ...
https://www.merck.healthinkonline.com/ merckTools/AssessMerckSourceCAGE.asp - 19k - Cached - Similar pages
screening questions - CAGE assessment
Aquarius - UK Midlands charity providing advice and counselling on alcohol and
drugs problems.
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Livingston County Council Alcohol & Substance Abuse - Assessment
It was not a test. It was the assessment.
Subject: It was not a test. It was the assessment.
nm
Assessment or Impression
Is it an AAMT rule to automatically number the diagnoses in the Assessment or Impression of an H&P or soap even if the dictator does not? TIA!
Should EKG be expanded in Assessment?
Subject: Should EKG be expanded in Assessment?
ASSESSMENT: Abnormal EKG.
question about assessment
Subject: question about assessment
Doc states CABG and mitral valve repair. He clearly states this together. Can this be listed as one assessment? Or should mitral valve repair be next number??
pulmonary assessment
Subject: pulmonary assessment
admitted for elective mediastinoscopy, s/l radio-gram-coscopy?? and left bronchotomy.
Assessment: Vaginitis DX. I never heard of DX?? thanks
Subject: Assessment: Vaginitis DX. I never heard of DX?? thanks
Under assessment: UNCOMPELLING EMG results
Subject: Under assessment: UNCOMPELLING EMG results
Is uncompelling a word?
Or is it noncompelling?
Thanks!
Assessment: Dry skin (s/l ictiosis).
Subject: Assessment: Dry skin (s/l ictiosis).
:-)
Geriatric Assessment Unit
Subject: Geriatric Assessment Unit
.
Oh...assessment is diagnosis..so I would type it out nm
Subject: Oh...assessment is diagnosis..so I would type it out nm
xx
"HO" assessment (alcoholism)
Subject: "HO" assessment (alcoholism)
Has anybody ever heard "EtOH" pronounced as "aitch oh"? Or know what "HO assessment" could mean in relation to alcohol treatment?
"Patient was not eligible for HO assessment."
Thank you!
Plan
Subject: Plan
CBC with differential, type and cross for 20 units, electrolytes P3, P4, PT, PTT, EKG, PA and lateral chest pulmonary function test.
I'm just in school for Med Trans. I love this website. I'm always confused when it comes to listing labs. I need help on the above. Thank you so much.
Plan help please!
Subject: Plan help please!
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.
thanks!
Plan help please!
Subject: Plan help please!
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.
Plan.... UA and CNS or C&S?? thank you
Subject: Plan.... UA and CNS or C&S?? thank you
Do you have to have a plan?
Subject: Do you have to have a plan?
Where I work, if they don't say "plan", they don't get a "plan".
That's what I plan to do.
Subject: That's what I plan to do.
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.
s/l topo or tolpol for fetal assessment
Subject: s/l topo or tolpol for fetal assessment
Hi! Need help as soon as possible. Typing history and physical for admission of a woman in labor. Here is what is dicated:
Fetal heart rate tracing is in the 140s and reassuring with good variability, accelerations, and no decelerations. (s/l topo or tolpol) is minimal if at all.
Thanks in advance!!
It is Mallampati. A classification used in ariway assessment.
Subject: It is Mallampati. A classification used in ariway assessment.
The number would be Class IV
Thanks for your reply. I will type CAM in the assessment and see what my manager says. nm
Subject: Thanks for your reply. I will type CAM in the assessment and see what my manager says. nm
nm
Assessment: s/l maseno fracture right ankle. nm
Subject: Assessment: s/l maseno fracture right ankle. nm
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!!
Thanks!!
s/l her-plan-jet-ick lesions
Subject: s/l her-plan-jet-ick lesions
s/l her-plan-jet-ick lesions in the mouth and throat
this is a 17 month old with excessive drooling and fever.
that sounds like a plan
Subject: that sounds like a plan
nm
CIWA-Clinical Institute Withdrawal Assessment nm
Subject: CIWA-Clinical Institute Withdrawal Assessment nm
He goes right into the Assessment of elevate PSA and bilat. iguin. hernia
Subject: He goes right into the Assessment of elevate PSA and bilat. iguin. hernia
CIWA-Clinical Institute Withdrawal Assessment
Subject: CIWA-Clinical Institute Withdrawal Assessment
score
Think you need CIWA - Clinical Institute Withdrawal Assessment nm
Subject: Think you need CIWA - Clinical Institute Withdrawal Assessment nm
x
Is this directions for something or what? A plan at the end of a scan? nm
Subject: Is this directions for something or what? A plan at the end of a scan? nm
s
In plan he very plainly says says need to rule out
Subject: In plan he very plainly says says need to rule out
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."
Plan: Check CMP and s/l iris ads
Subject: Plan: Check CMP and s/l iris ads
In plan, doc says check s/l FH LSH. How would this be typed --
Subject: In plan, doc says check s/l FH LSH. How would this be typed --
plan of coagulation? planned? WAG
Subject: plan of coagulation? planned? WAG
ASSESMENT/PLAN COMBINED?
Subject: ASSESMENT/PLAN COMBINED?
 WHen doing a SOAP NOTE
Can you Combine Assessment/Plan or are you supposed to seperate?
Even if doctor doesn't dictate a new paragraph? Thanks!
Thanks!!! no he says pila plan but cant find that--see more
Subject: Thanks!!! no he says pila plan but cant find that--see more
he diagnosed condition as blepheritis so that will work. thank you!!!!!
clinical institute withdrawal assessment (CIWA) protocol. nm
Subject: clinical institute withdrawal assessment (CIWA) protocol. nm
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