Assignment Prompt & Instructions
– 2 years ago
**files (4)**
– ## SOAPNote2ComprehensiveSOAPCardioRespiratory.docx
– ## EvaluationandManagementEMScoreSheet8985-2-1.pdf
– GroupSOAPRubricandTemplate.docx
– ComprehensiveSOAPNoteExample.doc2.pdf
**## SOAPNote2ComprehensiveSOAPCardioRespiratory.docx**
**Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!**
**Directions: Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.**
·
**Upload a copy of your completed SOAP note.**
·
**Upload a copy of the evaluation & management score sheet.**
**Case Study:** A 47-year-old African-American man presents to your office for a follow-up visit. He was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm Hg. He vaguely remembered being told in the past that his blood pressure was “borderline.” He feels fine, has no complaints, and his review of systems is entirely negative. He does not smoke cigarettes, drinks “a couple of beers on the weekends,” and does not exercise regularly. He has a sedentary job. His father died of a stroke at the age of 69. His mother is alive and in good health at the age of 72. He has two siblings and is not aware of any chronic medical issues that they have. In the office today, his blood pressure is 156/96 mm Hg in his left arm and 152/98 mm Hg in the right arm. He is afebrile, his pulse is 78 beats/min, respiratory rate 14 breaths/min, he is 70-in tall, and weighs 210 lb. A general physical examination is normal.
**## EvaluationandManagementEMScoreSheet8985-2-1.pdf**
E/M Documentation Auditor’s Instructions
1. History
Refer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which
best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to
identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type
of history.
After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.
HPI: Status of chronic conditions:
q 1 condition q 2 conditions q 3 conditions
q
Status of
1-2 chronic
Status of 3
chronic
conditions conditionsOR
HPI (history of present illness) elements:
q Location q Severity q Timing q Modifying factors
q Quality q Duration q Context q Associated signs and symptoms
q
Brief
(1-3)
Extended
(4 or more)
ROS (review of systems):
q Constitutional q Ears,nose, q GI q Integumentaryq Endo
(wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph
q Eyes q Card/vasc q Musculo q Neuro q All/immuno
q Resp q Psych q All others negative
q
None
q
Pertinent to
problem
(1 system)
q
Extended
(2-9 systems)
*Complete
PFSH (past medical, family, social history) areas:
q Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)
q Family history (a review of medical events in the patient's family, including diseases which may be
hereditary or place the patient at risk)
q Social history (an age appropriate review of past and current activities)
plete ROS: 10 or more systems or the pertinent positives and/or negatives of
q
None
q
Pertinent
(1 history area)
e**Complet
y(2 or 3 histor
areas)
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED -COMPRE
HENSIVE
q
T
O
R
Y
I
S
H
*Com
some systems with a statement “all others negative”.
**Complete PFSH: 2 history areas: a) Established Patients – Office (Outpatient) Care; b) Emergency Department.
3 history areas: a) New Patients – Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care;
c) Initial Hospital Observation; d) Initial Nursing Facility Care.
NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record
information about the PFSH. Please refer to procedure code descriptions.
2. Examination
Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.
Circle the type of examination within the appropriate grid in Section 5.
Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM
Affected body area or organ system and other symptomatic or related organ system(s)
(additional systems up to total of 7)
EXPANDED PROBLEM
FOCUSED EXAM
Extended exam of affected area(s) and other symptomatic or related organ system(s)
(additional systems up to total of 7 or more depth than above) DETAILED EXAM
General multi-system exam (8 or more systems) or complete exam of a single organ system
(complete single exam not defined in these instructions) COMPREHENSIVE EXAM
A
M
E
X
Body areas:
q Head, including face q Chest, including breasts and axillae
q Back, including spine qGenitalia, groin, buttocks
Organ systems:
q
q
Abdomen q Neck
Each extremity
q q q
1 body
area or
system
Up to 7
systems
Up to 7 8 or more
systems systems
q Constitutional q Ears,nose, q Resp q Musculo q Psych
) (e.g., vitals, gen app mouth, throat q GI q Skin
q Eyes q Cardiovascular q GU q Neuro
q Hem/lymph/imm
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED COMPRE-
HENSIVE
q
– 1 –
q
q
q
3. Medical Decision Making
Number of Diagnoses or Treatment Options
Identify each problem or treatment option mentioned in the record.
Enter the number in each of the categories in Column B in the table
below. (There are maximum number in two categories.)
Number of Diagnoses or Treatment Options
A B X C = D
Problem(s) Status Number Points Result
Self-limited or minor
(stable, improved or worsening) Max = 2 1
Est. problem (to examiner); stable, improved 1
Est. problem (to examiner); worsening 2
New problem (to examiner); no additional
workup planned
Max = 1
3
New prob. (to examiner); add. workup planned 4
TOTAL
Multiply the number in columns B & C and put the product in column D.
Enter a total for column D.
Bring total to line A in Final Result for Complexity (table below)
Amount and/or Complexity of Data Reviewed
For each category of reviewed data identified, circle the number in the points
column. Total the points.
Amount and/or Complexity of Data Reviewed
Reviewed Data Points
1
1
1
1
1
2
2
Review and/or order of clinical lab tests
Review and/or order of tests in the radiology section of CPT
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
Decision to obtain old records and/or obtain history from
someone other than patient
Review and summarization of old records and/or obtaining
history from someone other than patient and/or discussion of
case with another health care provider
Independent visualization of image, tracing or specimen itself
(not simply review of report)
TOTAL
Bring total to line C in Final Result for Complexity (table below)
Use the risk table below as a guide to assign risk factors. It is understood that the table below does not
contain all specific instances of medical care; the table is intended to be used as a guide. Circle the
most appropriate factor(s) in each category. The overall measure of risk is the highest level circled.
Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality
Level of
Risk
Presenting Problem(s) Diagnostic Procedure(s)
Ordered
Management Options
Selected
Minimal
• One self-limited or minor problem,
e.g., cold, insect bite, tinea corporis
• Laboratory tests requiring venipuncture
• Chest x-rays
• EKG/EEG
• Urinalysis
• Ultrasound, e.g., echo
• KOH prep
• Rest
• Gargles
• Elastic bandages
• Superficial dressings
Low
• Two or more self-limited or minor problems
• One stable chronic illness, e.g., well controlled
hypertension or non-insulin dependent diabetes,
cataract, BPH
• Acute uncomplicated illness or injury, e.g., cystitis, allergic
rhinitis, simple sprain
• Physiologic tests not under stress, e.g.,pulmonary
function tests
• Non-cardiovascular imaging studies with contrast,
e.g., barium enema
• Superficial needle biopsies
• Clincal laboratory tests requiring arterial puncture
• Skin biopsies
• Over-the-counter drugs
• Minor surgery with no identified risk factors
• Physical therapy
• Occupational therapy
• IV fluids without additives
Moderate
• One or more chronic illnesses with mild exacerbation,
progression, or side effects of treatment
• Two or more stable chronic illnesses
• Undiagnosed new problem with uncertain prognosis,
e.g., lump in breast
• Acute illness with systemic symptoms, e.g.,
pyelonephritis, pneumonitis, colitis
• Acute complicated injury, e.g., head injury with brief loss
of consciousness
• Physiologic tests under stress, e.g., cardiac stress test,
fetal contraction stress test
• Diagnostic endoscopies with no identified risk factors
• Deep needle or incisional biopsy
• Cardiovascular imaging studies with contrast and no
identified risk factors, e.g., arteriogram cardiac cath
• Obtain fluid from body cavity, e.g., lumbar puncture,
thoracentesis, culdocentesis
• Minor surgery with identified risk factors
• Elective major surgery (open, percutaneous or
endoscopic) with no identified risk factors
• Prescription drug management
• Therapeutic nuclear medicine
• IV fluids with addititives
• Closed treatment of fracture or dislocation without
manipulation
High
• One or more chronic illnesses with severe exacerbation,
progression, or side effects of treatment
• Acute or chronic illnesses or injuries that may pose a threat to
life or bodily function, e.g., multiple trauma, acute MI,
pulmonary embolus, severe respiratory distress, progressive
severe rheumatoid arthritis, psychiatric illness with potential
threat to self or others, peritonitis, acute renal failure
• An abrupt change in neurologic status, e.g., seizure, TIA,
weakness or sensory loss
• Cardiovascular imaging studies with contrast with
identified risk factors
• Cardiac electrophysiological tests
• Diagnostic endoscopies with identified risk factors
• Discography
• Elective major surgery (open, percutaneous or
endoscopic with identified risk factors)
• Emergency major surgery (open, percutaneous or
endoscopic)
• Parenteral controlled substances
• Drug therapy requiring intensive monitoring for toxicity
• Decision not to resuscitate or to de-escalate care
because of poor prognosis
Final Result for Complexity
Draw a line down any column with 2 or 3 circles to identify the type of decision making in
that column. Otherwise, draw a line down the column with the 2nd circle from the left.
After completing this table, which classifies complexity, circle the type of decision
making within the appropriate grid in Section 5.
Final Result for Complexity
A Number diagnoses or
treatment options
≤ 1
Minimal
2
Limited
3
Multiple
≥ 4
Extensive
B Highest Risk Minimal Low Moderate High
C Amount and complexity
of data
≤ 1
Minimal
or low
2
Limited
3
Multiple
≥ 4
Extensive
Type of decision making STRAIGHT-
FORWARD
LOW
COMPLEX.
MODERATE
COMPLEX.
HIGH
COMPLEX.
4. Time
If the physician documents total time and suggests that counseling or coordinating care dominates
(more than 50%) the encounter, time may determine level of service. Documentation may refer to:
prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk
reduction or discussion with another health care provider.
Face-to-face in outpatient setting
Does documentation reveal total time? Time: Unit/floor in inpatient setting Yes No
Does documentation describe the content of counseling or coordinating care? Yes No
Does documentation reveal that more than half of the time was counseling or
coordinating care? Yes No
If all answers are "yes", select level based on time.
– 2 –
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D
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M
A
K
I
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5. L E V E L O F S E R V I C E
New Office, Outpatient and Emergency Room
New Office / Outpatient / ER Established Office / Outpatient
Requires 3 components within shaded area Requires 2 components within shaded area
History
PF
ER: PF
EPF
ER: EPF
D
ER: EPF
C
ER: D
C
ER: C Minimal
problem
that may
not
require
presence
of
physician
PF EPF D C
Examination
PF
ER: PF
EPF
ER: EPF
D
ER: EPF
C
ER: D
C
ER: C
PF EPF D C
Complexity
of medical
decision
SF
ER: SF
SF
ER: L
L
ER: M
M
ER: M
H
ER: H SF L M H
Average time
(minutes)
ER has no average
time
10 New (99201)
ER (99281)
20 New (99202)
ER (99282)
30 New (99203)
ER (99283)
45 New (99204)
ER (99284)
60 New (99205)
ER (99285)
5
(99211)
10
(99212)
15
(99213)
25
(99214)
40
(99215)
Level I II III IV V I II III IV V
Hospital Care Initial Hospital/Observation Subsequent Hospital/Observation
Requires 3 components within shaded area Requires 2 components within shaded area
History D/C C C PF interval EPF interval D interval
Examination D/C C C PF EPF D
Complexity of medical
decision SF/L M H SF/L M H
Average time (minutes)
30 Init hosp (99221)
30 Init observ Care
(99218)
50 Init hosp (99222)
50 Init observ Care
(99219)
70 Init hosp (99223)
70 Init observ Care
(99220)
15 Sub hosp (99231)
15 Sub observ care
(99224)
25 Sub hosp (99232)
25 Sub observ care
(99225)
35 Sub hosp (99233)
35 Sub observ care
(99226)
Level I II III I II III
Nursing Facility
Care Initial Nursing Facility
Requires 3 components within shaded area
Subsequent Nursing Facility
Requires 2 components within shaded area
Other Nursing Facility
(Annual Assessment)
Requires 3 components within shaded area
History D/C C C PF interval EPF interval D interval C interval D interval
Examination D/C C C PF EPF D C C
Complexity of medical
decision SF/L M H SF L M H L/M
Average time (minutes) 25
99304
35
99305
45
99306
10
99307
15
99308
25
99309
35
99310
30
99318
Level I II III I II III IV
Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services and Home Care
Requires 3 components within shaded area Requires 2 onents within shaded area
History PF EPF D C C PF interval EPF interval D interval C interval
Examination PF EPF D C C PF EPF D C
Complexity of
medical decision SF L M M H SF L M M/H
Average time
(minutes)
20
Domiciliary (99324)
Home care (99341)
30
Domiciliary (99325)
Home care (99342)
45
Domiciliary (99326)
Home care (99343)
60
Domiciliary (99327)
Home care (99344)
75
Domiciliary (99328)
Home care (99345)
15
Domiciliary (99334)
Home care (99347)
25
Domiciliary (99335)
Home care (99348)
40
Domiciliary (99336)
Home care (99349)
60
Domiciliary (99337)
Home care (99350)
Level I II III IV V I II III IV
PF = Problem focused EPF = Expanded problem focused D = Detailed C = Comprehensive SF = Straightforward L = Low M = Moderate H = High
– 3 –
Establishe
dcomp
New
– Novitas Solutions Documentation Worksheet
– History Section
– Examination Section
– Medical Decision Making Section
– Time Section
– Level of Service Grids
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**## SOAPNote2ComprehensiveSOAPCardioRespiratory.docx**
**Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!**
**Directions: Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.**
·
**Upload a copy of your completed SOAP note.**
·
**Upload a copy of the evaluation & management score sheet.**
**Case Study:** A 47-year-old African-American man presents to your office for a follow-up visit. He was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm Hg. He vaguely remembered being told in the past that his blood pressure was “borderline.” He feels fine, has no complaints, and his review of systems is entirely negative. He does not smoke cigarettes, drinks “a couple of beers on the weekends,” and does not exercise regularly. He has a sedentary job. His father died of a stroke at the age of 69. His mother is alive and in good health at the age of 72. He has two siblings and is not aware of any chronic medical issues that they have. In the office today, his blood pressure is 156/96 mm Hg in his left arm and 152/98 mm Hg in the right arm. He is afebrile, his pulse is 78 beats/min, respiratory rate 14 breaths/min, he is 70-in tall, and weighs 210 lb. A general physical examination is normal.
**## EvaluationandManagementEMScoreSheet8985-2-1.pdf**
E/M Documentation Auditor’s Instructions
1. History
Refer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which
best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to
identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type
of history.
After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.
HPI: Status of chronic conditions:
q 1 condition q 2 conditions q 3 conditions
q
Status of
1-2 chronic
Status of 3
chronic
conditions conditionsOR
HPI (history of present illness) elements:
q Location q Severity q Timing q Modifying factors
q Quality q Duration q Context q Associated signs and symptoms
q
Brief
(1-3)
Extended
(4 or more)
ROS (review of systems):
q Constitutional q Ears,nose, q GI q Integumentaryq Endo
(wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph
q Eyes q Card/vasc q Musculo q Neuro q All/immuno
q Resp q Psych q All others negative
q
None
q
Pertinent to
problem
(1 system)
q
Extended
(2-9 systems)
*Complete
PFSH (past medical, family, social history) areas:
q Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)
q Family history (a review of medical events in the patient's family, including diseases which may be
hereditary or place the patient at risk)
q Social history (an age appropriate review of past and current activities)
plete ROS: 10 or more systems or the pertinent positives and/or negatives of
q
None
q
Pertinent
(1 history area)
e**Complet
y(2 or 3 histor
areas)
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED -COMPRE
HENSIVE
q
T
O
R
Y
I
S
H
*Com
some systems with a statement “all others negative”.
**Complete PFSH: 2 history areas: a) Established Patients – Office (Outpatient) Care; b) Emergency Department.
3 history areas: a) New Patients – Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care;
c) Initial Hospital Observation; d) Initial Nursing Facility Care.
NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record
information about the PFSH. Please refer to procedure code descriptions.
2. Examination
Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.
Circle the type of examination within the appropriate grid in Section 5.
Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM
Affected body area or organ system and other symptomatic or related organ system(s)
(additional systems up to total of 7)
EXPANDED PROBLEM
FOCUSED EXAM
Extended exam of affected area(s) and other symptomatic or related organ system(s)
(additional systems up to total of 7 or more depth than above) DETAILED EXAM
General multi-system exam (8 or more systems) or complete exam of a single organ system
(complete single exam not defined in these instructions) COMPREHENSIVE EXAM
A
M
E
X
Body areas:
q Head, including face q Chest, including breasts and axillae
q Back, including spine qGenitalia, groin, buttocks
Organ systems:
q
q
Abdomen q Neck
Each extremity
q q q
1 body
area or
system
Up to 7
systems
Up to 7 8 or more
systems systems
q Constitutional q Ears,nose, q Resp q Musculo q Psych
) (e.g., vitals, gen app mouth, throat q GI q Skin
q Eyes q Cardiovascular q GU q Neuro
q Hem/lymph/imm
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED COMPRE-
HENSIVE
q
– 1 –
q
q
q
3. Medical Decision Making
Number of Diagnoses or Treatment Options
Identify each problem or treatment option mentioned in the record.
Enter the number in each of the categories in Column B in the table
below. (There are maximum number in two categories.)
Number of Diagnoses or Treatment Options
A B X C = D
Problem(s) Status Number Points Result
Self-limited or minor
(stable, improved or worsening) Max = 2 1
Est. problem (to examiner); stable, improved 1
Est. problem (to examiner); worsening 2
New problem (to examiner); no additional
workup planned
Max = 1
3
New prob. (to examiner); add. workup planned 4
TOTAL
Multiply the number in columns B & C and put the product in column D.
Enter a total for column D.
Bring total to line A in Final Result for Complexity (table below)
Amount and/or Complexity of Data Reviewed
For each category of reviewed data identified, circle the number in the points
column. Total the points.
Amount and/or Complexity of Data Reviewed
Reviewed Data Points
1
1
1
1
1
2
2
Review and/or order of clinical lab tests
Review and/or order of tests in the radiology section of CPT
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
Decision to obtain old records and/or obtain history from
someone other than patient
Review and summarization of old records and/or obtaining
history from someone other than patient and/or discussion of
case with another health care provider
Independent visualization of image, tracing or specimen itself
(not simply review of report)
TOTAL
Bring total to line C in Final Result for Complexity (table below)
Use the risk table below as a guide to assign risk factors. It is understood that the table below does not
contain all specific instances of medical care; the table is intended to be used as a guide. Circle the
most appropriate factor(s) in each category. The overall measure of risk is the highest level circled.
Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality
Level of
Risk
Presenting Problem(s) Diagnostic Procedure(s)
Ordered
Management Options
Selected
Minimal
• One self-limited or minor problem,
e.g., cold, insect bite, tinea corporis
• Laboratory tests requiring venipuncture
• Chest x-rays
• EKG/EEG
• Urinalysis
• Ultrasound, e.g., echo
• KOH prep
• Rest
• Gargles
• Elastic bandages
• Superficial dressings
Low
• Two or more self-limited or minor problems
• One stable chronic illness, e.g., well controlled
hypertension or non-insulin dependent diabetes,
cataract, BPH
• Acute uncomplicated illness or injury, e.g., cystitis, allergic
rhinitis, simple sprain
• Physiologic tests not under stress, e.g.,pulmonary
function tests
• Non-cardiovascular imaging studies with contrast,
e.g., barium enema
• Superficial needle biopsies
• Clincal laboratory tests requiring arterial puncture
• Skin biopsies
• Over-the-counter drugs
• Minor surgery with no identified risk factors
• Physical therapy
• Occupational therapy
• IV fluids without additives
Moderate
• One or more chronic illnesses with mild exacerbation,
progression, or side effects of treatment
• Two or more stable chronic illnesses
• Undiagnosed new problem with uncertain prognosis,
e.g., lump in breast
• Acute illness with systemic symptoms, e.g.,
pyelonephritis, pneumonitis, colitis
• Acute complicated injury, e.g., head injury with brief loss
of consciousness
• Physiologic tests under stress, e.g., cardiac stress test,
fetal contraction stress test
• Diagnostic endoscopies with no identified risk factors
• Deep needle or incisional biopsy
• Cardiovascular imaging studies with contrast and no
identified risk factors, e.g., arteriogram cardiac cath
• Obtain fluid from body cavity, e.g., lumbar puncture,
thoracentesis, culdocentesis
• Minor surgery with identified risk factors
• Elective major surgery (open, percutaneous or
endoscopic) with no identified risk factors
• Prescription drug management
• Therapeutic nuclear medicine
• IV fluids with addititives
• Closed treatment of fracture or dislocation without
manipulation
High
• One or more chronic illnesses with severe exacerbation,
progression, or side effects of treatment
• Acute or chronic illnesses or injuries that may pose a threat to
life or bodily function, e.g., multiple trauma, acute MI,
pulmonary embolus, severe respiratory distress, progressive
severe rheumatoid arthritis, psychiatric illness with potential
threat to self or others, peritonitis, acute renal failure
• An abrupt change in neurologic status, e.g., seizure, TIA,
weakness or sensory loss
• Cardiovascular imaging studies with contrast with
identified risk factors
• Cardiac electrophysiological tests
• Diagnostic endoscopies with identified risk factors
• Discography
• Elective major surgery (open, percutaneous or
endoscopic with identified risk factors)
• Emergency major surgery (open, percutaneous or
endoscopic)
• Parenteral controlled substances
• Drug therapy requiring intensive monitoring for toxicity
• Decision not to resuscitate or to de-escalate care
because of poor prognosis
Final Result for Complexity
Draw a line down any column with 2 or 3 circles to identify the type of decision making in
that column. Otherwise, draw a line down the column with the 2nd circle from the left.
After completing this table, which classifies complexity, circle the type of decision
making within the appropriate grid in Section 5.
Final Result for Complexity
A Number diagnoses or
treatment options
≤ 1
Minimal
2
Limited
3
Multiple
≥ 4
Extensive
B Highest Risk Minimal Low Moderate High
C Amount and complexity
of data
≤ 1
Minimal
or low
2
Limited
3
Multiple
≥ 4
Extensive
Type of decision making STRAIGHT-
FORWARD
LOW
COMPLEX.
MODERATE
COMPLEX.
HIGH
COMPLEX.
4. Time
If the physician documents total time and suggests that counseling or coordinating care dominates
(more than 50%) the encounter, time may determine level of service. Documentation may refer to:
prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk
reduction or discussion with another health care provider.
Face-to-face in outpatient setting
Does documentation reveal total time? Time: Unit/floor in inpatient setting Yes No
Does documentation describe the content of counseling or coordinating care? Yes No
Does documentation reveal that more than half of the time was counseling or
coordinating care? Yes No
If all answers are "yes", select level based on time.
– 2 –
M
E
D
I
C
A
L
D
E
C
I
S
I
O
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M
A
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I
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G
5. L E V E L O F S E R V I C E
New Office, Outpatient and Emergency Room
New Office / Outpatient / ER Established Office / Outpatient
Requires 3 components within shaded area Requires 2 components within shaded area
History
PF
ER: PF
EPF
ER: EPF
D
ER: EPF
C
ER: D
C
ER: C Minimal
problem
that may
not
require
presence
of
physician
PF EPF D C
Examination
PF
ER: PF
EPF
ER: EPF
D
ER: EPF
C
ER: D
C
ER: C
PF EPF D C
Complexity
of medical
decision
SF
ER: SF
SF
ER: L
L
ER: M
M
ER: M
H
ER: H SF L M H
Average time
(minutes)
ER has no average
time
10 New (99201)
ER (99281)
20 New (99202)
ER (99282)
30 New (99203)
ER (99283)
45 New (99204)
ER (99284)
60 New (99205)
ER (99285)
5
(99211)
10
(99212)
15
(99213)
25
(99214)
40
(99215)
Level I II III IV V I II III IV V
Hospital Care Initial Hospital/Observation Subsequent Hospital/Observation
Requires 3 components within shaded area Requires 2 components within shaded area
History D/C C C PF interval EPF interval D interval
Examination D/C C C PF EPF D
Complexity of medical
decision SF/L M H SF/L M H
Average time (minutes)
30 Init hosp (99221)
30 Init observ Care
(99218)
50 Init hosp (99222)
50 Init observ Care
(99219)
70 Init hosp (99223)
70 Init observ Care
(99220)
15 Sub hosp (99231)
15 Sub observ care
(99224)
25 Sub hosp (99232)
25 Sub observ care
(99225)
35 Sub hosp (99233)
35 Sub observ care
(99226)
Level I II III I II III
Nursing Facility
Care Initial Nursing Facility
Requires 3 components within shaded area
Subsequent Nursing Facility
Requires 2 components within shaded area
Other Nursing Facility
(Annual Assessment)
Requires 3 components within shaded area
History D/C C C PF interval EPF interval D interval C interval D interval
Examination D/C C C PF EPF D C C
Complexity of medical
decision SF/L M H SF L M H L/M
Average time (minutes) 25
99304
35
99305
45
99306
10
99307
15
99308
25
99309
35
99310
30
99318
Level I II III I II III IV
Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services and Home Care
Requires 3 components within shaded area Requires 2 onents within shaded area
History PF EPF D C C PF interval EPF interval D interval C interval
Examination PF EPF D C C PF EPF D C
Complexity of
medical decision SF L M M H SF L M M/H
Average time
(minutes)
20
Domiciliary (99324)
Home care (99341)
30
Domiciliary (99325)
Home care (99342)
45
Domiciliary (99326)
Home care (99343)
60
Domiciliary (99327)
Home care (99344)
75
Domiciliary (99328)
Home care (99345)
15
Domiciliary (99334)
Home care (99347)
25
Domiciliary (99335)
Home care (99348)
40
Domiciliary (99336)
Home care (99349)
60
Domiciliary (99337)
Home care (99350)
Level I II III IV V I II III IV
PF = Problem focused EPF = Expanded problem focused D = Detailed C = Comprehensive SF = Straightforward L = Low M = Moderate H = High
– 3 –
Establishe
dcomp
New
– Novitas Solutions Documentation Worksheet
– History Section
– Examination Section
– Medical Decision Making Section
– Time Section
– Level of Service Grids
**GroupSOAPRubricandTemplate.docx**
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**ComprehensiveSOAPNoteExample.doc2.pdf**
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**## SOAPNote2ComprehensiveSOAPCardioRespiratory.docx**
**Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!**
**Directions: Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.**
·
**Upload a copy of your completed SOAP note.**
·
**Upload a copy of the evaluation & management score sheet.**
**Case Study:** A 47-year-old African-American man presents to your office for a follow-up visit. He was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm Hg. He vaguely remembered being told in the past that his blood pressure was “borderline.” He feels fine, has no complaints, and his review of systems is entirely negative. He does not smoke cigarettes, drinks “a couple of beers on the weekends,” and does not exercise regularly. He has a sedentary job. His father died of a stroke at the age of 69. His mother is alive and in good health at the age of 72. He has two siblings and is not aware of any chronic medical issues that they have. In the office today, his blood pressure is 156/96 mm Hg in his left arm and 152/98 mm Hg in the right arm. He is afebrile, his pulse is 78 beats/min, respiratory rate 14 breaths/min, he is 70-in tall, and weighs 210 lb. A general physical examination is normal.
**## EvaluationandManagementEMScoreSheet8985-2-1.pdf**
E/M Documentation Auditor’s Instructions
1. History
Refer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which
best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to
identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type
of history.
After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.
HPI: Status of chronic conditions:
q 1 condition q 2 conditions q 3 conditions
q
Status of
1-2 chronic
Status of 3
chronic
conditions conditionsOR
HPI (history of present illness) elements:
q Location q Severity q Timing q Modifying factors
q Quality q Duration q Context q Associated signs and symptoms
q
Brief
(1-3)
Extended
(4 or more)
ROS (review of systems):
q Constitutional q Ears,nose, q GI q Integumentaryq Endo
(wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph
q Eyes q Card/vasc q Musculo q Neuro q All/immuno
q Resp q Psych q All others negative
q
None
q
Pertinent to
problem
(1 system)
q
Extended
(2-9 systems)
*Complete
PFSH (past medical, family, social history) areas:
q Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)
q Family history (a review of medical events in the patient's family, including diseases which may be
hereditary or place the patient at risk)
q Social history (an age appropriate review of past and current activities)
plete ROS: 10 or more systems or the pertinent positives and/or negatives of
q
None
q
Pertinent
(1 history area)
e**Complet
y(2 or 3 histor
areas)
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED -COMPRE
HENSIVE
q
T
O
R
Y
I
S
H
*Com
some systems with a statement “all others negative”.
**Complete PFSH: 2 history areas: a) Established Patients – Office (Outpatient) Care; b) Emergency Department.
3 history areas: a) New Patients – Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care;
c) Initial Hospital Observation; d) Initial Nursing Facility Care.
NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record
information about the PFSH. Please refer to procedure code descriptions.
2. Examination
Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.
Circle the type of examination within the appropriate grid in Section 5.
Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM
Affected body area or organ system and other symptomatic or related organ system(s)
(additional systems up to total of 7)
EXPANDED PROBLEM
FOCUSED EXAM
Extended exam of affected area(s) and other symptomatic or related organ system(s)
(additional systems up to total of 7 or more depth than above) DETAILED EXAM
General multi-system exam (8 or more systems) or complete exam of a single organ system
(complete single exam not defined in these instructions) COMPREHENSIVE EXAM
A
M
E
X
Body areas:
q Head, including face q Chest, including breasts and axillae
q Back, including spine qGenitalia, groin, buttocks
Organ systems:
q
q
Abdomen q Neck
Each extremity
q q q
1 body
area or
system
Up to 7
systems
Up to 7 8 or more
systems systems
q Constitutional q Ears,nose, q Resp q Musculo q Psych
) (e.g., vitals, gen app mouth, throat q GI q Skin
q Eyes q Cardiovascular q GU q Neuro
q Hem/lymph/imm
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED COMPRE-
HENSIVE
q
– 1 –
q
q
q
3. Medical Decision Making
Number of Diagnoses or Treatment Options
Identify each problem or treatment option mentioned in the record.
Enter the number in each of the categories in Column B in the table
below. (There are maximum number in two categories.)
Number of Diagnoses or Treatment Options
A B X C = D
Problem(s) Status Number Points Result
Self-limited or minor
(stable, improved or worsening) Max = 2 1
Est. problem (to examiner); stable, improved 1
Est. problem (to examiner); worsening 2
New problem (to examiner); no additional
workup planned
Max = 1
3
New prob. (to examiner); add. workup planned 4
TOTAL
Multiply the number in columns B & C and put the product in column D.
Enter a total for column D.
Bring total to line A in Final Result for Complexity (table below)
Amount and/or Complexity of Data Reviewed
For each category of reviewed data identified, circle the number in the points
column. Total the points.
Amount and/or Complexity of Data Reviewed
Reviewed Data Points
1
1
1
1
1
2
2
Review and/or order of clinical lab tests
Review and/or order of tests in the radiology section of CPT
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
Decision to obtain old records and/or obtain history from
someone other than patient
Review and summarization of old records and/or obtaining
history from someone other than patient and/or discussion of
case with another health care provider
Independent visualization of image, tracing or specimen itself
(not simply review of report)
TOTAL
Bring total to line C in Final Result for Complexity (table below)
Use the risk table below as a guide to assign risk factors. It is understood that the table below does not
contain all specific instances of medical care; the table is intended to be used as a guide. Circle the
most appropriate factor(s) in each category. The overall measure of risk is the highest level circled.
Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality
Level of
Risk
Presenting Problem(s) Diagnostic Procedure(s)
Ordered
Management Options
Selected
Minimal
• One self-limited or minor problem,
e.g., cold, insect bite, tinea corporis
• Laboratory tests requiring venipuncture
• Chest x-rays
• EKG/EEG
• Urinalysis
• Ultrasound, e.g., echo
• KOH prep
• Rest
• Gargles
• Elastic bandages
• Superficial dressings
Low
• Two or more self-limited or minor problems
• One stable chronic illness, e.g., well controlled
hypertension or non-insulin dependent diabetes,
cataract, BPH
• Acute uncomplicated illness or injury, e.g., cystitis, allergic
rhinitis, simple sprain
• Physiologic tests not under stress, e.g.,pulmonary
function tests
• Non-cardiovascular imaging studies with contrast,
e.g., barium enema
• Superficial needle biopsies
• Clincal laboratory tests requiring arterial puncture
• Skin biopsies
• Over-the-counter drugs
• Minor surgery with no identified risk factors
• Physical therapy
• Occupational therapy
• IV fluids without additives
Moderate
• One or more chronic illnesses with mild exacerbation,
progression, or side effects of treatment
• Two or more stable chronic illnesses
• Undiagnosed new problem with uncertain prognosis,
e.g., lump in breast
• Acute illness with systemic symptoms, e.g.,
pyelonephritis, pneumonitis, colitis
• Acute complicated injury, e.g., head injury with brief loss
of consciousness
• Physiologic tests under stress, e.g., cardiac stress test,
fetal contraction stress test
• Diagnostic endoscopies with no identified risk factors
• Deep needle or incisional biopsy
• Cardiovascular imaging studies with contrast and no
identified risk factors, e.g., arteriogram cardiac cath
• Obtain fluid from body cavity, e.g., lumbar puncture,
thoracentesis, culdocentesis
• Minor surgery with identified risk factors
• Elective major surgery (open, percutaneous or
endoscopic) with no identified risk factors
• Prescription drug management
• Therapeutic nuclear medicine
• IV fluids with addititives
• Closed treatment of fracture or dislocation without
manipulation
High
• One or more chronic illnesses with severe exacerbation,
progression, or side effects of treatment
• Acute or chronic illnesses or injuries that may pose a threat to
life or bodily function, e.g., multiple trauma, acute MI,
pulmonary embolus, severe respiratory distress, progressive
severe rheumatoid arthritis, psychiatric illness with potential
threat to self or others, peritonitis, acute renal failure
• An abrupt change in neurologic status, e.g., seizure, TIA,
weakness or sensory loss
• Cardiovascular imaging studies with contrast with
identified risk factors
• Cardiac electrophysiological tests
• Diagnostic endoscopies with identified risk factors
• Discography
• Elective major surgery (open, percutaneous or
endoscopic with identified risk factors)
• Emergency major surgery (open, percutaneous or
endoscopic)
• Parenteral controlled substances
• Drug therapy requiring intensive monitoring for toxicity
• Decision not to resuscitate or to de-escalate care
because of poor prognosis
Final Result for Complexity
Draw a line down any column with 2 or 3 circles to identify the type of decision making in
that column. Otherwise, draw a line down the column with the 2nd circle from the left.
After completing this table, which classifies complexity, circle the type of decision
making within the appropriate grid in Section 5.
Final Result for Complexity
A Number diagnoses or
treatment options
≤ 1
Minimal
2
Limited
3
Multiple
≥ 4
Extensive
B Highest Risk Minimal Low Moderate High
C Amount and complexity
of data
≤ 1
Minimal
or low
2
Limited
3
Multiple
≥ 4
Extensive
Type of decision making STRAIGHT-
FORWARD
LOW
COMPLEX.
MODERATE
COMPLEX.
HIGH
COMPLEX.
4. Time
If the physician documents total time and suggests that counseling or coordinating care dominates
(more than 50%) the encounter, time may determine level of service. Documentation may refer to:
prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk
reduction or discussion with another health care provider.
Face-to-face in outpatient setting
Does documentation reveal total time? Time: Unit/floor in inpatient setting Yes No
Does documentation describe the content of counseling or coordinating care? Yes No
Does documentation reveal that more than half of the time was counseling or
coordinating care? Yes No
If all answers are "yes", select level based on time.
– 2 –
M
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5. L E V E L O F S E R V I C E
New Office, Outpatient and Emergency Room
New Office / Outpatient / ER Established Office / Outpatient
Requires 3 components within shaded area Requires 2 components within shaded area
History
PF
ER: PF
EPF
ER: EPF
D
ER: EPF
C
ER: D
C
ER: C Minimal
problem
that may
not
require
presence
of
physician
PF EPF D C
Examination
PF
ER: PF
EPF
ER: EPF
D
ER: EPF
C
ER: D
C
ER: C
PF EPF D C
Complexity
of medical
decision
SF
ER: SF
SF
ER: L
L
ER: M
M
ER: M
H
ER: H SF L M H
Average time
(minutes)
ER has no average
time
10 New (99201)
ER (99281)
20 New (99202)
ER (99282)
30 New (99203)
ER (99283)
45 New (99204)
ER (99284)
60 New (99205)
ER (99285)
5
(99211)
10
(99212)
15
(99213)
25
(99214)
40
(99215)
Level I II III IV V I II III IV V
Hospital Care Initial Hospital/Observation Subsequent Hospital/Observation
Requires 3 components within shaded area Requires 2 components within shaded area
History D/C C C PF interval EPF interval D interval
Examination D/C C C PF EPF D
Complexity of medical
decision SF/L M H SF/L M H
Average time (minutes)
30 Init hosp (99221)
30 Init observ Care
(99218)
50 Init hosp (99222)
50 Init observ Care
(99219)
70 Init hosp (99223)
70 Init observ Care
(99220)
15 Sub hosp (99231)
15 Sub observ care
(99224)
25 Sub hosp (99232)
25 Sub observ care
(99225)
35 Sub hosp (99233)
35 Sub observ care
(99226)
Level I II III I II III
Nursing Facility
Care Initial Nursing Facility
Requires 3 components within shaded area
Subsequent Nursing Facility
Requires 2 components within shaded area
Other Nursing Facility
(Annual Assessment)
Requires 3 components within shaded area
History D/C C C PF interval EPF interval D interval C interval D interval
Examination D/C C C PF EPF D C C
Complexity of medical
decision SF/L M H SF L M H L/M
Average time (minutes) 25
99304
35
99305
45
99306
10
99307
15
99308
25
99309
35
99310
30
99318
Level I II III I II III IV
Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services and Home Care
Requires 3 components within shaded area Requires 2 onents within shaded area
History PF EPF D C C PF interval EPF interval D interval C interval
Examination PF EPF D C C PF EPF D C
Complexity of
medical decision SF L M M H SF L M M/H
Average time
(minutes)
20
Domiciliary (99324)
Home care (99341)
30
Domiciliary (99325)
Home care (99342)
45
Domiciliary (99326)
Home care (99343)
60
Domiciliary (99327)
Home care (99344)
75
Domiciliary (99328)
Home care (99345)
15
Domiciliary (99334)
Home care (99347)
25
Domiciliary (99335)
Home care (99348)
40
Domiciliary (99336)
Home care (99349)
60
Domiciliary (99337)
Home care (99350)
Level I II III IV V I II III IV
PF = Problem focused EPF = Expanded problem focused D = Detailed C = Comprehensive SF = Straightforward L = Low M = Moderate H = High
– 3 –
Establishe
dcomp
New
– Novitas Solutions Documentation Worksheet
– History Section
– Examination Section
– Medical Decision Making Section
– Time Section
– Level of Service Grids
**GroupSOAPRubricandTemplate.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/groupsoaprubricandtemplate-docx-10170163)
**ComprehensiveSOAPNoteExample.doc2.pdf**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/comprehensivesoapnoteexample-doc2-pdf-10170161)