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Medical Chart Notes
A chart note usually follows a very simple pattern:
Subjective (what the patient thinks) = S
Objective (what the doctor thinks) = O
Assessment (what the diagnosis is) = A
Plan (what happens next) = P
Not all providers dictate the “SOAP” note format; sometimes they simply state in a narrative way the same information. In that case, you would just leave out the abbreviated headings or, if the client prefers, the headings, Subjective, Objective, Assessment and Plan information may be defined (with some practice) so that the transcriptionist organizes the appropriate data under the headings where it belongs.
SNOCAMP (migrated clinical SOAP record)
What is SNOCAMP?:
SNOCAMP is a new adaptation of a medical records format that includes the same four elements of the SOAP record (SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN). It is designed to add enough information to allow better coding of the E/M (Evaluation and Management) CPT codes. It has accordingly added:
1. Nature of Illness (high/medium/low severity)
3. Medical Decision Making (high/medium/low severity)
|NEW||Nature of Illness (high/medium/low severity)|
|NEW||Medical Decision Making (high/medium/low severity)|
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