This Rapid Tutorial sets the tone for this module by providing a deeper dive into the “S” of a SOAP note. Subjective information is far more than just recording the patient’s pain scale. The purpose of the subjective section of the daily ROV note is to record the patient’s progress and to incrementally tell the story of his/her return to health.
The subjective sections of each daily note within an episode serve as a missive about the patient’s assessment of his/her condition. Providers record the context on a visit-to-visit basis and follow the patient’s functional improvement. Important details about the medical necessity of the case are found in the subjective portion of the note. Follow along here to learn the most critical elements of recording a patient’s subjective assessment.
This Rapid Tutorial sets the tone for this module and for the entire course focused on Documentation of Evaluation and Management. Start your training by better understanding what a routine office visit looks like in the context of your documentation.
Often, providers forget the ROV within “episodic care” must have a minimum set of targeted “updated” (comparative) subjective data components from the previous visit, or initial visit when applicable, of this episode. These routine visits provide the necessary elements to continue to prove the medical necessity for active treatment and the plan itself.
Coding for maintenance care is different from coding for active care. And there are as many opinions on how it should be done as there are ways to do it. It’s critical to remember that for Medicare maintenance, the rules are different from coding for non-Medicare maintenance care. This short training explores the differences and...