Running head: UNIT 1 INDIVIDUAL PROJECT
American Intercontinental University
Unit 1 Individual Project
HLTH250-1002B-01 Introduction to Coding and Billing
May 2, 2010
The SOAP (subjective, objective, assessment/analysis, plan) is used to help medical professionals collect and organize medical information on patients (SOAP format, 2009). This format is used to document data in a clear and well organized structure.
S – 47 YO male PT with C/C of pain and burning in the LUQ. The patient states that it seems to get worse after alcohol consumption. PT is suffering from LOA, nausea, and diarrhea. PT is C/O of pain in the lower lumbar area that ...view middle of the document...
This is the assessment area. In this area the doctor will list the potential or actual problems that could be identified as a result of the data that has been collected. In most cases, nothing can be in this area that has not been addressed in the “S” or “O” section.
P – PT is to be sent to lab for MRI and ERCP. The CBC shows an infection going on in the body. PT is instructed to watch alcohol and fatty food consumption. Patient will be put on antibiotics of penicillin 1000mg 2X daily for infection and MS Contin 750mg BID for pain. PT instructed to RTO in four days for discussion of further treatment depending on test results.
This is the Plan area. It is in this area that the doctor will decide what is to be done based on data and results founded so far during the examination.
The following steps will be completed after the SOAP has been finished.
1. Recording Patients’ Information – the patients’ information from the insurance card will be updated into the computer for billing. The patient’s insurance is Humana Gold.
2. Recording Diagnoses, Procedures, Charges, and Payments for Patient Visit – Once the patient has met with the physician, the diagnosis and procedure codes will then be recorded in the billing computer program and a bill will be generated (Medical Billing, 2006).
3. Creation and transmission of claims to insurance company – Once all of the correct billing information is entered and a bill is generated, it will be checked for correct coding to avoid...