Focused SOAP Notes
Usually, we describe a focused (or episodic) visit as when a patient comes in who is ill with a complaint such as URI or UTI. The patient may be someone who also comes in for chronic condition visits, but this particular visit is focused on the chief complaint. It is helpful to differentiate between the types of visits the same person might make. For example, when your diabetic patient comes in because of a UTI, you are only focusing on the sick or illness complaint.
Please note: When documenting assessment or review of systems, use proper descriptive terms. Do not write normal or negative in the assessment.
When you get into practice, it will be important to understand that billing for services will depend on having proper documentation in all areas of the patients chart. When a patient is charged for services and the chart does not support the billing code, it can be considered fraudulent and serious consequences could result.
Please be sure to put your own name on the assignment being submitted.
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