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Running head: UNIT 1 INDIVIDUAL PROJECT

Kimberly Young

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 sometimes gets worse after food consumption. States this has been occurring for four weeks or more. The PT has NKA.
This is the subjective data. It includes all the things the patient has stated is bothering them. Some of the items that are included in this area are the presenting concern, history of concern, allergies.
O – VS appear to be erratic with fever, the PR is high, and PT has extremely low BP. CBC done with WBC very high. Jaundice is evident on PT. Lungs clear. Pain in LUQ obvious when examined. PT is also C/O swelling in ankles and dizziness. Denies dysuria. Infection is obvious.
This is the objective data. It contains the observations made by the doctor during examination. Some of the information included in this area is the patient’s vital signs, general appearance and mental status. Laboratory results may also be included in this area.
A – This 47 YO male has been found to be symptomatic of possible pancreatitis that has been occurring off and on for about a month. Patient is feverish and is showing signs of malaise. Findings suggest possible gall stone pancreatitis or acute pancreatitis. This is due to the occurrence of pain and nausea after…...

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