soap # 1 daisy day date of service: patient name: dob

All Rights Reserved – Career Coders, LLC

SOAP # 1 – Daisy Day Date of Service: 02/05/2021

Patient Name: Daisy Day

DOB: 09/18/2017

Chief Complaint - Other

HPI Debbie is a 4-year-old child Yesterday they went to dinner Running fevers and threw up Sister came in and said that her sisters' legs were kicking Has not had one in 2 years Fell asleep and then went to the store No more vomiting, diarrhea, runny nose or pain with urination

Past Medical History:

• History of urinary tract infections, Otitis Media, seizure from fever (05/15)

Family History:

• diabetes material grandmother

Social History:

• Lives with 2 sisters

• Parents – divorced, split custodial rights

• Does anyone who lives in the home smoke tobacco? No

Examination

• General Appearance: active, NAD • HEENT: Eyes: non-injected and no exudates. Ears: TM’s membranes pearly w/good landmarks.

Nose: no nasal discharge Tonsils: no erythema or exudate and not enlarged Oropharynx: moist mucosa and normal oropharynx

• Cardio: Heart sound: increased HR, regular rhythm • Lungs: clear to auscultation bilaterally • Abdomen: no abdominal tenderness, non-distended • Skin: warm, well perfused. No lesions, no rash

Assessment/Plan:

Daisy is a 4 year-old child with h/o febrile seizures who had sz activity this morning (unwitnessed by

parents), fever and vomiting. She is well appearing in office with supple neck. She also has h/o UTI.

Attempted to give urine sample but unable in office.

COVID testing performed

Call if worsening symptoms, neck stiffness, persistent vomiting or fevers, concerns

Fever - R50.9 Fever, unspecified - Instructed to give Children’s Tylenol 160/mg/5mL oral suspension

Electronically Signed: Debbie Johns, MD 2/06/21 at 3:44 pm


SOAP # 2 – Robert Redman

Date of Service: 01/12/2021

Patient Name: Robert Redman

DOB: 07/15/1953

PROVIDER: Andrew Johnson, MD

CHIEF COMPLAINT: Acute Visit

Nursing documentation:

November 30, 2020 – Weight 159 lbs.

January 12, 2021 – Weight 129 lbs.

SpO2 on Room Air @ Rest: Unable to get readings on oximeters due to cyanosis, attempted twice

Patient has nocturnal O2 but sometimes used during the day.

Vital Signs: 97.5F

HISTORY:

No history of gout but flare of symptoms in feet, discussed results of arterial u/s which was normal for

upper extremities. Complains of some fatigue and thinks it is from waking constantly due to foot pain.

ROS: Negative fever or chills, headache, double vision or blurry vision, ear pain, throat pain, nasal

congestion, neck pain or stiffness, cough, chest pain, palpitations, shortness of breath, abdominal pain,

nausea, vomiting diarrhea, weight gain, weight loss, dysuria, urgency, frequency, hematuria, difficult

speaking difficult swallowing, swollen or tender lymph nodes, bruising, hematochesia, hematemesis,

rash extremity pain or swelling weakness, numbness.

PAST MEDICAL, FAMILY AND SOCIAL HISTORY:


• Parkinsonism

• Persistent tremor

• Elevated PSA

• Hypoxemia

• COPD

• Hypertension

• History of tobacco

• Sensorineural hearing loss, bilaterally

• Insomnia

• Hyperlipidemia

Family History:

Social History:

• Tobacco – quit in 2000

Allergies – Patient denies any allergies to medications

Medications have been reviewed with the patient to ensure that all active medications are listed and

have determined how the patient is taking the medications and updated as necessary.


EXAMINATION:

General: Alert and oriented x 3 – NAD

Eyes: PERRL EOMI

Neck: Supple, NT negative adenopathy

CV: Regular rate, rhythm no murmur

Respiratory: Clear to auscultation bilaterally

Abdomen – soft non tender positive bowel sounds

Back: negative for CVA tenderness

Extremities: negative cyanosis, clubbing or edema

Neuro: grossly normal, negative cerebellar signs

Skin: negative rash, warm and dry

• Diet exercise and all normal and abnormal test results have been reviewed with the person –

no questions

• Colorectal Cancer Screen: patient declines screening

ASSESSMENT:

Diagnosis/Plan:

• Parkinson’s – G20

• Probably gout – M10.9

PLAN:

Diclofenac cream for flares, check uric acid level, rtc annual

Approximately 35 minutes spent with patient answering questions.

Electronically Signed: Andrew Johnson, MD 01/12/21 13:45


SOAP #3 – Robert Redman (Hospital) Patient Name: Robert Redman

DOB: 07/15/53

DOS: 01/14/21

Service: Donald Pace, MD Hospitalist Admit

Chief Complaint: Generalize Weakness

HPI:

Robert is a 66 year old male with a history of HTN, COPD, and Parkinson’s who presents for

approximately 2-3 days of progressive and extreme weakness, fatigue, uncontrollable chills,

hypotension, nausea and vomiting. Patient’s wife and son are at bedside and help provide history. Wife

reports over the last couple of days the patient has become increasingly fatigued and weak. EMS was

called and patient was found to be hypotensive with systolic blood pressures in the 70s. He states the

weakness is generalized and not located to any specific region of the body. The patient has a history of

double pneumonia in the past but this event there were no indications or symptoms of pneumonia which

is unlike his previous event when he was diagnosed with double pneumonia. Prior to presentation to the

ED the patient additionally reports lightheadedness and one episode of emesis. He also endorses some

mild chest tightness, but states the tightness feels similar to COPD symptoms and may be secondary to

missing a nebulizer treatment due to fatigue. He denies any associated abdominal pain, dysuria or

burning with urination.

Of note, the patient endorses an unintentional weight loss of approximately 30 pounds in the last 2

months. He states this is secondary to his decreased appetite, and his wife reports it is “difficult to get

him to eat anything”. No significant changes or severity with his Parkinson’s. Will admit to ICU for

treatment of septic shock.


• COPD

• Hypertension

• Parkinson Disease

Past Surgical History:

• Dental surgery – removal of all teeth

Family History:

• Father died at 67 due to Alzheimer’s, pneumonia, and alcoholism

• Mother died at 72 due to AAA - Abdominal Aortic Aneurysm

• Brother died at 62 of brain cancer

Social History:

• Marital Status: Married – Jayme

• Number of Children – 5

• Smoking: Former cigarette smoker – quit 2000

• Does not drink alcohol

Allergies – patient allergic to penicillin

Review of Systems:

• Constitutional: positive for malaise/fatigue. Negative for chills/fever

• Respiratory: negative for cough

• Cardiovascular: negative for chest pain

• Gastrointestinal: positive for vomiting, negative for abdominal pain

• Musculoskeletal: negative for myalgias

• Skin: negative for itching/rash

• Neurological: positive for tremors


• Psychiatric/Behavioral: Negative for depression. The patient is not nervous/anxious.

• All other systems reviewed and are negative

Examination:

Vitals: BP: 86/55 upon arrival SpO2: 89% Pulse: 95 BMI 18.9

General: Well appearing, A&O x 3

Eyes and ENT: PERRLA, EOMI

Respiratory: Low-pitched wheezing (rhonchi) indicated in left lung. Per radiology - Left midlung

consolidation is most suggestive of a pneumonia

CV: Regular rate and rhythm

GI: Soft, nontender, nondistended, normoactive bowel sounds

Skin: warm and dry, no rashes, no ulcers

Musculoskeletal: no joint effusions, deformities, no clubbing, no cyanosis

Neuro: follows commands, CN’s II-XII grossly intact

Psychiatric: Normal mood and affect, indicates he feels like he is in a fog and not sure of everything that

is going on

Results/Verification of Data Review:

• POCT Lactate

• Hepatic Function Panel

• CBC with Auto Differential

• Lipase

• Smear review

• CMP

• Blood Culture

• POCT Troponin

• POCT Lactate

Radiology – Xr Chest Single View Result date: 01/14/21

Examination: XR CHEST SINGLE VIEW Comparison: 1/18/19 History: Weakness Findings: Chronic

pulmonary hyperexpansion. New left midlung-ill defined consolidation. No pneumothorax, edema or

effusion. Cardiac and hilar contour size is within normal limits. Osseous structures are intact.

Impression: Left midlung consolidation is most suggestive of a pneumonia. Radiographic follow-up 4-6

weeks to document resolution and exclude the presence of a pulmonary nodule is recommended. Report

E-signed by: Daniel Donaldson, MD 1/14/21 9PM

Assessment and Plan

Septic Shock

• Hypotension

• Leukocytosis

• EKG show atrial fibrillation with ventricular rate of 89

• Troponin 0 0.00

• WBS 23

• Lactate 3.12 will trend

• Begin levo fed, goal to keep mean arterial pressure greater than 60 mmHg

• Admit to ICU

• Continue lactated Ringer’s at 125 cc/h

• Continue Azithromycin and Cefepime

• Follow blood and urine cultures


• Check urinalysis

• Check serial lactates

• Sepsis protocol

• Check Procalcitonin

• Check CT chest abdomen pelvis

• Check Lipase

• Recheck AM BMP and CBC

Acute kidney injury

• Cr 3.03.. baseline 1.3

• Hold Lisinopril

• Avoid nephrotoxic meds

• Hold topical diclofenac

• Recheck BMP

Chest Pain

• Patient has left-sides chest and feels like it is related to COPD

• Denies exertional anginal symptom

• Start ASA 81 mg

• Troponin 0.0

• Check serial troponins

• Check echocardiogram

Bilateral Pneumonia

• Chest x-ray 7/1 left lung consolidation is most suggestive of a pneumonia.

• Recheck chest x-ray in am.

COPD without acute exacerbation

• Oxygen, duo nebs, RT protocol, pulmonary toilet

• Continue home albuterol MDI

Parkinson’s disease

• Continue home carbidopa levodopa

• Hold Inderal

Hypertension

• Hold home HCTZ, lisinopril and Inderal given hypotension

I spent 40 minutes in Critical Care with this patient due to systems failing including septic shock and

kidney failure. This is excluding procedures and not overlapping with other providers.

Advanced Care Plan – Full code

By signing my name below, I, Stacie Schmitt, attest that this documentation has been prepared under

the direction in the presence of Donald Pace, MD Electronically signed: Stacie Schmitt, Scribe 01/14/21

9:45 PM

I, Dr. Donald Pace, personally performed the services described in this documentation. All medical record

entries made by the scribe were at my direction and in my presence. I have reviewed the chart and

discharge instructions (if applicable) and agree that the record reflects my personal performance and is

accurate and complete. Pace, Donald, MD 01/14/21 @ 11:06 PM

Electronically signed by Donald Pace, MD 01/14/21 at 11:06 PM

Presentation by :

Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPB, CPC-I, CCS-P, CMRS, CMCS

Career Coders, LLC All Rights Reserved

Dissecting Documentation

AGENDA

• Have the following notes available for dissection

• SOAP # 1 – Daisy Day

• SOAP # 3 – Robert Redman (Office Encounter)

• SOAP # 3 – Robert Redman (Hospital Admit)


S O A P

All Rights Reserved - Career Coders, LLC

S

O

A

P

Subjective or History Part of Note Includes the History of Present Illness, Review of Systems, Past Medical, Family and Social History

Observation is the hands-on examination of the

patient by the provider

AssessmentThe providers diagnosis for Medical Decision Making

(MDM)

PlanPlan on current and future treatment of patient and is

part of Medical Decision Making (MDM)

REVIEW NOT AUDIT

• How to review the documentation to look for errors.

• This is not an audit to determine the level.

• Purpose is the verify documentation and was it properly billed on the CMS-1500.

• Exercises help understand what is contained in a SOAP note.

• We are not auditing to determine level, only reviewing documentation


WHAT ARE WE REVIEWING?

• Patient correct name?

• Date of Service

• Physician signature identified and is the same provider's name on the

CMS1500

• Electronic signature and sign off date by the physician

• Billed as Incident-to?

• Identified on CMS-1500, documentation, supervising physician



• Chief Complaint

• History, Exam, Plan and Assessment documented

• Not audited, listed

• Diagnosis

• Diagnosis addressed

• Listed on CMS-1500

• Time documentation

• Is the encounter based on time and is it supported with detail



• Documentation clearly paints the picture of the patient’s illness, injury or condition

• Conflicting information

• Patterns/Trends

• Padding of documentation

• Cloned notes

• Copy/Paste


DISSECTING NOTES

• Now we are going to go through some notes

• You will need the following notes to help answer questions

• These are actual notes I have encountered

• Daisy Day - SOAP #1

• Robert Redman (Office Visit) – SOAP #2

• Robert Redman (Hospital Admit) – SOAP #3


VERIFING THE DOCUMENTATION

• Patient Daisy Day – SOAP #1

• Verify:

• Patient name

• Date of service

• Physician signature

• Sign off date

• Billed as Incident-to

• Chief Complaint


• Diagnosis billed and listed on CMS-1500



Daisy Day – SOAP #1


Date of Service: 02/05/2021Patient Name: Daisy Day

DOB: 09/18/2017

Electronically Signed: Debbie Johns, MD 2/06/21 at 3:44 pm

CHIEF COMPLAINT, HISTORYChief Complaint - Other

HPI • Debbie is a 4-year-old child• Yesterday they went to dinner • Running fevers and threw up • Sister came in and said that her sisters' legs were kicking • Has not had one in 2 years• Fell asleep and then went to the store• No more vomiting, diarrhea, runny nose or pain with urination

Past Medical History: History of urinary tract infections, Otitis Media, seizure from fever (05/15)Family History: diabetes material grandmotherSocial History: Lives with 2 sisters, Parents – divorced, split custodial rights, Does anyone who lives in the home smoke tobacco? No


EXAMINATION, ASSESSMENT, PLAN

Examination•General Appearance: active, NAD•HEENT: Eyes: non-injected and no exudates. Ears: TM’s membranes pearly w/good landmarks. Nose: no nasal discharge Tonsils: no erythema or exudate and not enlarged Oropharynx: moist mucosa and normal oropharynx•Cardio: Heart sound: increased HR, regular rhythm•Lungs: clear to auscultation bilaterally •Abdomen: no abdominal tenderness, non-distended•Skin: warm, well perfused. No lesions, no rash


ASSESSMENT AND PLAN

R50.9

Assessment/Plan:

• Daisy is a 4-year-old child with h/o febrile seizures who had sz activity this morning

(unwitnessed by parents), fever and vomiting. She is well appearing in office with

supple neck. She also has h/o UTI.• Attempted to give urine sample but unable in office.

• COVID testing performed

• Call if worsening symptoms, neck stiffness, persistent vomiting or fevers, concerns

Fever - R50.9 Fever, unspecified - Instructed to give Children’s Tylenol 160/mg/5mL oral

suspension

Is diagnosis noted correctly on CMS-1500?

VERIFING THE DOCUMENTATION

• Patient Robert Redman – SOAP #2

• Verify:

• Patient name

• Date of service

• Physician signature

• Sign off date

• Billed as Incident-to

• Chief Complaint


• Diagnosis billed and listed on CMS-1500



Robert Redman – SOAP #2




DOB: 07/15/1953

PROVIDER: Andrew Johnson, MD


Electronically Signed: Andrew Johnson, MD 01/12/21 13:45

CHIEF COMPLAINT, HISTORYCHIEF COMPLAINT: Acute Visit

Nursing documentation:

• November 30, 2020 – Weight 159 lbs January 12, 2021 – Weight 129 lbs.

• SpO2 on Room Air @ Rest: Unable to get readings on oximeters due to cyanosis, attempted twice

• Patient has nocturnal O2 but sometimes used during the day. Vital Signs: 97.5F

HISTORY:

No history of gout but flare of symptoms in feet, discussed results of arterial u/s which was normal for

upper extremities. Complains of some fatigue and thinks it is from waking constantly due to foot pain.

ROS: Negative fever or chills, headache, double vision or blurry vision, ear pain, throat pain, nasal

congestion, neck pain or stiffness, cough, chest pain, palpitations, shortness of breath, abdominal pain,

nausea, vomiting/diarrhea, weight gain, weight loss, dysuria, urgency, frequency, hematuria, difficult

speaking difficult swallowing, swollen or tender lymph nodes, bruising, hematochesia, hematemesis, rash

extremity pain or swelling weakness, numbness.


PAST MEDICAL, FAMILY, SOCIAL HISTORY



Parkinsonism, Persistent tremor, Elevated PSA, Hypoxemia, COPD,

Hypertension, History of tobacco, Sensorineural hearing loss bilaterally,

Insomnia, Hyperlipidemia

Family History:

Social History: tobacco – quit in 2000

Allergies – Patient denies any allergies to medications

EXAMINATION

EXAMINATION: • General: Alert and oriented x 3 – NAD • Eyes: PERRL EOMI • Neck: Supple, NT negative adenopathy • CV: Regular rate, rhythm no murmur • Respiratory: Clear to auscultation bilaterally • Abdomen – soft non tender positive bowel sounds • Back: negative for CVA tenderness• Extremities: negative cyanosis, clubbing or edema • Neuro: grossly normal, negative cerebellar signs • Skin: negative rash, warm and dry


ASSESSMENT AND PLAN

G20

• Diet exercise and all normal and abnormal test results have been reviewed with the person – no questions

• Colorectal Cancer Screen: patient declines screening

ASSESSMENT:

Diagnosis/Plan:

• Parkinson’s

• Probably gout

PLAN:

Diclofenac cream for flares, check uric acid level, rtc annual


Is diagnosis noted correctly on CMS-1500?

M10.9

Robert Redman – SOAP #3 (Hospital)




DOB: 07/15/1953

PROVIDER: Donald Pace, MD

Electronically Signed: Donald Pace, MD 01/14/21 11:06 PM

CHIEF COMPLAINT, HISTORYChief Complaint: Generalize Weakness

HPI: Robert is a 66-year-old male with a history of HTN, COPD, and Parkinson’s who presents for approximately 2-3 days of progressive and extreme weakness, fatigue, uncontrollable chills, hypotension, nausea and vomiting. Patient’s wife and son are at bedside and help provide history. Wife reports over the last couple of days the patient has become increasingly fatigued and weak. EMS was called and patient was found to be hypotensive with systolic blood pressures in the 70s. He states the weakness is generalized and not located to any specific region of the body. The patient has a history of double pneumonia in the past but this event there were no indications or symptoms of pneumonia which is unlike his previous event when he was diagnosed with double pneumonia. Prior to presentation to the ED the patient additionally reports lightheadedness and one episode of emesis. He also endorses some mild chest tightness, but states the tightness feels similar to COPD symptoms and may be secondary to missing a nebulizer treatment due to fatigue. He denies any associated abdominal pain, dysuria or burning with urination. • Of note, the patient endorses an unintentional weight loss of approximately 30 pounds in the last 2 months. He states this is secondary to his decreased appetite, and his wife reports it is “difficult to get him to eat anything”. No significant changes or severity with his Parkinson’s. Will admit to ICU for treatment of septic shock.


ROS


Review of Systems:

• Constitutional: positive for malaise/fatigue. Negative for chills/fever

• Respiratory: negative for cough

• Cardiovascular: negative for chest pain

• Gastrointestinal: positive for vomiting, negative for abdominal pain

• Musculoskeletal: negative for myalgias

• Skin: negative for itching/rash

• Neurological: positive for tremors

• Psychiatric/Behavioral: Negative for depression. The patient is not

nervous/anxious.

• All other systems reviewed and are negative

PAST MEDICAL, FAMILY, SOCIAL HISTORY



• COPD

• Hypertension

• Parkinson Disease

Past Surgical History:

• Dental surgery – removal of all teeth

Family History:

• Father died at 67 due to Alzheimer’s, pneumonia, and alcoholism

• Mother died at 72 due to AAA - Abdominal Aortic Aneurysm

• Brother died at 62 of brain cancer

Social History:

• Marital Status: Married – Jayme

• Number of Children – 5

• Smoking: Former cigarette smoker – quit 2000

• Does not drink alcohol

Allergies – patient allergic to penicillin

EXAMINATIONExamination: • Vitals: BP: 86/55 upon arrival SpO2: 89% Pulse: 95 BMI 18.9 • General: Well appearing, A&O x 3• Eyes and ENT: PERRLA, EOMI • Respiratory: Clear to auscultation bilaterally. • CV: Regular rate and rhythm• GI: Soft, nontender, nondistended, normoactive bowel sounds• Skin: warm and dry, no rashes, no ulcers• Musculoskeletal: no joint effusions, deformities, no clubbing, no cyanosis• Neuro: follows commands, CN’s II-XII grossly intact • Psychiatric: Normal mood and affect, indicates he feels like he is in a fog and not

sure of everything that is going on


TESTING

Results/Verification of Data Review:

• POCT Lactate, Hepatic Function Panel, CBC with Auto Differential, Lipase, Smear

review, CMP, Blood Culture, POCT Troponin, POCT Lactate

Radiology – Xr Chest Single View Result date: 01/14/21

• Examination: XR CHEST SINGLE VIEW Comparison: 1/18/19 History: Weakness

Findings: Chronic pulmonary hyperexpansion. New left midlung-ill defined

consolidation. No pneumothorax, edema or effusion. Cardiac and hilar contour

size is within normal limits. Osseous structures are intact. Impression: Left midlung

consolidation is most suggestive of a pneumonia. Radiographic follow-up 4-6

weeks to document resolution and exclude the presence of a pulmonary nodule is

recommended. Report E-signed by: Daniel Donaldson, MD 1/14/21 9PM


ASSESSMENT AND PLANAssessment and Plan

Septic Shock

- Hypotension, Leukocytosis, EKG show atrial fibrillation with ventricular rate of 89,

Troponin 0 0.00, WBS 23, Lactate 3.12 will trend, Begin levo fed, goal to keep mean

arterial pressure greater than 60 mmHg

- Admit to ICU, Continue lactated Ringer’s at 125 cc/h, Continue Azithromycin and

Cefepime, Follow blood and urine cultures, Check urinalysis, Check serial lactates, Sepsis

protocol, Check Procalcitonin

- Check CT chest abdomen pelvis, Check Lipase, Recheck AM BMP and CBC

Acute kidney injury

- Cr 3.03.. baseline 1.3, Hold Lisinopril, Avoid nephrotoxic meds, Hold topical diclofenac,

Recheck BMP

ASSESSMENT AND PLANChest Pain

- Patient has left-sides chest and feels like it is related to COPD. Denies exertional anginal

symptom

- Start ASA 81 mg, Troponin 0.0, Check serial troponins, Check echocardiogram

Bilateral Pneumonia

- Chest x-ray 7/1 left lung consolidation is most suggestive of a pneumonia. Recheck

chest x-ray in am. COPD without acute exacerbation. Oxygen, duo nebs, RT protocol,

pulmonary toilet. Continue home albuterol MDI

Parkinson’s disease

- Continue home carbidopa levodopa, Hold Inderal

Hypertension

- Hold home HCTZ, lisinopril and Inderal given hypotension

PROBLEMS – OFFICE vs HOSPITAL ENCOUNTER• Time documentation

• Office minimal questions asked of the patient – he documented 30 minutes answering questions

• Hospital – 40 minutes for critical care• Allergies to medication

• Office - No allergies documented and patient denies • Hospital - patient is allergic to penicillin

• Weight Loss • Office - did not address the 25-30 lb• Hospital - unintentional weight loss noted

• Review of Systems (ROS) Cyanosis/Shortness of breath• Office documented no cyanosis – nurse documented cyanosis and

could not get a pulse ox and No shortness of breath – patient came into office with portable O2


PROBLEMS – OFFICE vs HOSPITAL ENCOUNTER

• Examination

• Office - Respiratory: Clear to auscultation bilaterally

• Hospital - wheezing and pneumonia detected

• Office - Extremities: negative cyanosis (but is positive per nurse)

• Diagnosis

• Office Visit – Parkinsons, possible gout

• Hospital – pneumonia, septic shock


PROBLEMS – OFFICE vs HOSPITAL ENCOUNTER

• Office Visit

• Diagnosis of Parkinsons

• Carbidopa prescribed 4 years ago

• Hospital• Per Neurologist - does not have Parkinson but has essential tremors

• Carbidopa caused kidney damage

• Wife was witness to providers office encounter


DOCUMENTATION ERRORS

• You can see many times the documentation is not perfect

• Provider's signature indicates all the information is true and accurate.

• MUST read their notes before signing


FACTS PUBLISHED IN REGARD TO EMR

• Journal of American Medical Association, New England Journal of Medicine

• Medication Errors

• Copy/paste or cloned notes

• Dependence on spell check

• Templates

• Speech recognition

• Drop down menu with limited choices

• Poor design

• Increased fraud/abuse/Compromise healthcare of patients


COPY AND PASTE

• Is it permitted???

• Do you check previous encounter for copy/paste?

• Can lead to errors such as:

• Symptoms

• Medications

• Histories

• Multitude of errors

• Authentication of author


TEMPLATES

• Templates

• Conflicting information

• Not relevant to age, gender

• End Result – more risk to providers


EXAMPLE OF INCORRET TEMPLATE

• 9-year-old seen for burn with urination diagnosed with acute cystitis

• Plan: RX meds as directed. Instructed patient of safe use of meds, purpose, dosage, importance of finishing prescribed medications and possible toxic affects. Increase PO fluids, limit caffeine. Wipe from front to back, void frequently and after sexual intercourse. Patient verbalized understanding


PADDING OF EXAM OR CLONING

• Padding the documentation is adding more information than is required.

• Example:

• Ears bilateral TM’s pearly gray with good light reflex, EAC’s are clear, external ears intact bilaterally and nontender. No mastoid tenderness, no pain on manipulation, no gross hearing loss noted. Nose normal nasal mucosa and turbinate's bilaterally, external exam of nose finds no abnormalities. Oral pharynx no inflammation, lips, teeth and gums intact. PND clear with no sinus tenderness on palpation.


SPEECH RECOGNITION

• Homophone • A word that is pronounced the same as another word but

differs in meaning

• Examples:• Flour or flower• accept — except• appose - oppose • Dialects pick up words differently or if not said clearly

• Pancreas “Pan Grease”

• Doctors must review before signing off

• Can change the medical record and patient condition


Homophone Errors

• The patient is 23-year-old female who presents with headache and bitten tongue. Per parents the patient has a history of grandma seizures.

• Chief Complaint – “bazaar behavior”

• 89-year-old female with history of remote middle cerebral ornery smoke ( cerebral coronary stroke)

• Walking Leonia instead of Walking Pneumonia

• "The patient has had a hard time breeding" (breathing).


Humorous Documentation Errors

• Indication for flex sig – “blood when whipping himself” (wiping)

• Reason for leaving AMA – “pt wants to live” (leave)

• “He is allergic to wives.” (hives)

• Asking about DNR status – “I want my wife to receive artificial insemination”

• Between you and me, we ought to be able to get this lady pregnant.

• The lab test indicated abnormal lover function (liver function)

• Physician asked the patient if he smoked, Doctor documented, “like Bill Clinton, does not inhale”.

• "Testicles are mildly prominent." (It was a brain MRI)


Just Darn Funny

• This 56-year-old patient brought into ED via ambulance with diabetic ketoacidosis. Wife states he has been complaining of nausea, vomiting and abdominal pain. He is Type I diabetic and is not under control with his diet or insulin regimen…………… Examination - Upon exam “I found a moon pie hidden in his underwear".


PHYSICIANS NEED OUR HELP

• Physician need to document their thought processes

• Not taught in medical school

• Educate on proper documentation

• Teaching documentation, not coding


Remind Your Physicians

Just because you got paid for it

doesn’t mean you will get to keep it,

it all depends on

YOUR DOCUMENTATION


Thank You from Loveland, ColoradoThe Sweetheart City


Email: [email protected]: www.CareerCoders.com

mailto:[email protected]

http://www.careercoders.com/

soap # 1 daisy day date of service: patient name: dob

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