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account specifics require SOAP format for all dictators - gagirl


Posted: Aug 18, 2010

Okay, i have a doc that is dicating pretty much an H&P but account specifics require SOAP format for all dicators. Would most everything go under subjective heading such as social history, family history, no known allergies, etc.? I know PE will go under objective, but would the ROS go under objective as well or subjective? Thanks!

Company should provide you with sample documents - sm

[ In Reply To ..]
My account is the same, SOAP format. However, the hospital wants certain headings bolded, some headings not bolded, and everything in a certain order. I think the hospital preference trumps the SOAP format. You ought to have a reference sample somewhere in your account information. Otherwise, you are correct, all the headings that you mention are under the SUBJECTIVE section (including ROS because it's the patient's subjective report).


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