What a great thread. Brian has a terrific solution for those of us, (like me!) that us a "modified" SOAP format. Every item in the plan should be attributed to the appropriate item(s) in the assessment. AC scrambles that completely the way I have been using it. I am going to try Brian's work around. The staff need the match up in order to get the proper ICD-9's onto lab slips, x-ray orders and so forth. (This past Monday I had a request for a PET scan going out with Acute Bronchitis as the DX because the MA didn't recognize Actinomycosis or Hemoptysis as lung related.)


Martin T. Sechrist, D.O.
Striving for the "Outcome Oriented Medical Record".