1) Compare and contrast the two documentation formats. Describe which format wou
ID: 466543 • Letter: 1
Question
1) Compare and contrast the two documentation formats. Describe which format would be best for the medical practice scenario. The formats are SOAP and SNOCAMP
2)In the following secenerio determine whether the visit is a consultation or a new patient and explain how you arrive at your decision. Kelly mills was sent to Dr .Sara class for evaluation of her peptic ulcer disease .Her family Physician , Dr Babinetz had seen Kelly in the office and needed the expert opinion of Dr. class regarding her gastrointestinal complaints . Dr Babinetz reviewed the upper gastro internal (GI) Study that Kelly brought with her to his office. He will need to order some additional studies and will see Kelly in follow –up in 3 weeks to discuss the results and her prognosis.
3) Describe what a medically unnecessary service is and provide an example of one.
4) List and define the two teaching physician modifiers
Please answer all the questions they are very important
Explanation / Answer
1. SOAP is a medical records format and includes the following elements - Subjective, Objective, Assessment and Plan. This format is used by health care providers for the purpose of writing notes in a patient's chart. The note is written in a specific order. As mentioned earlier the purpose is to write notes in a patient's chart and these notes are used for admission notes as well as medical histories.
Subjective section is the starting point of all SOAP notes. In this section the subjective observations of a patient is noted. An example would be observations made by the patient about the symptoms. The next section is Objective. In this section objective observations like pulse, blood pressure, body temperature etc. are included. The third section is Assessment. In this section diagnosis is included. The last section is Plan, and the plan of action for addressing the patient's problem is included.
SNOCAMP is also a medical records format. The four sections of subjective, objective, assessment and plan is common with the SOAP format. The additional sections include the following - Nature of Illness, Counseling and Medical decision making. Nature of illness section will mention the severity of the illness, whether it is low, medium or high severity. Counseling section details the nature of the counseling, the procedures, alternatives and risks, and the benefits of the management options with patient. Lastly, the medical decision making determines the complexity of the decision in terms of low, medium or high complexity.
The SNOCAMP format is better for the medical practice scenario for the simple reason that SNOCAMP is more explicit than SOAP. This format is more relevant for meeting the different needs of the physicians as well as the patients they attend to.
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