52 in 52 – Professor Stephanie Pough – Introduction to Medical Coding

Mon, 10/16/2017

I enjoyed a great class with Professor Pough and her class recently, when she reviewed SOAP note analysis and dissection.

The SOAP note (an acronym for subjective, objective, assessment, and plan/future plan) is a method of documentation employed by health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note

Subjective refers to anything the patient reports such as symptoms, complaints, family history, medical history, etc.  Objective is anything you as the clinician observe, such as the physical examination, diagnostics available like x-rays, etc.  Assessment includes a diagnosis, coding and vital signs.  Plan and Future Plan refer to treatment plan, referrals, diet, labs needed, etc.

I listened to the students’ knowledge and their questions.  They then developed SOAP notes by pairing up with classmates.  I offered to be a subject but I had no takers! 

The class concluded with a deeper discussion of ICD-10 for diagnosis and CPT coding for billing and insurance reimbursement.

It was great to see learning in action, and I look forward to future medical classes!

Posted by: 
Mary Beth Del Balzo, CW President