Part B Insider (Multispecialty) Coding Alert
Go Beyond The SOAP Note
Published on Wed Dec 17, 2003
When taking a history, many doctors are used to obtaining a simple Subjective Objective Assessment and Plan (SOAP) note, which provides all the information they need for the review of systems, but not enough information for the history of present illness or past family and social history, consultant Barbara Cobuzzi says.
"A SOAP note just reviews what's going on with the systems," she says. So you should encourage your physicians to think in terms of HPI and PFSH as well as ROS.
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