Medical Documentation

Medical Documentation

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A full-sized, tear-out version is included in Appendix B. Patient Examination An alternative to the exam checklist is a form with anatomical headings followed by ample room for the ... By using the SOAP format, the individual components of an E/M service can be easily recognized in the chart. Coding ... Subjective The subjective portion of the encounter includes all information the patient tells the physician.

Title:Medical Documentation
Author: Jerry G. Seare
Publisher:Medicode Incorporated - 1996-01-01

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