1. An eclectic group of documentation tools in ezSOAP

2. Learning Objectives What is important to document in exam Components of billing the exam Where to document test results How to write prescriptions in ezSOAP How to customize your ezSOAP pull downs Practice for this week

3. Exam documentation that is important For patient care For patient satisfaction For medicolegal purposes For billing New problems & consultations Established problems

4. Multi-System Exam Bullets SystemMaxSystemMaxSystemMax Constitutional2Cardiovascular7Musculoskeletal26 Eyes3Chest(breasts)2Lymphatic4 ENT/Mouth6Gastrointestinal5Integumentary2 Neck2GU-Male3Neurologic3 Respiratory4GU-Female6Psychiatric4

5. Determining Level of Exam BulletsSystems Problem Focused1+ Expanded Problem Focused6+1+ Detailed12+1+ Comprehensive (2+ each system)18+9+

6. Documenting Test Results Although objective data, contribute to Medical Decision Making ezSOAP puts this on second tab of O: Document your personal observations vs. review of a report vs. discussion with consultant(s)

7. Writing Prescriptions in ezSOAP Generic vs. Trade Name Dosages Common Infrequently used Pediatric Quantities Refills Authorizing refills Printing the prescriptions

8. Customizing ezSOAP Favorites S: Review of symptoms O: Normal vs. abnormals O: Test results P: Medication additions Medication name Default prescription Documentation for note

9. o Document as much of PE using drop downs as possible o Get preceptor feedback on whether you documented too little or too much o Document all your prescriptions from Prescription Writer – even those for Medicaid patients that have to be on tamper-proof forms