Other
NC Other, title (subdirectory/title OR solely title)
me MEDS
lb LAB FINDINGS
dg DIAGNOSTICS
hm RHM (Prevention)
ad Administrative
pr Procedures
gv Group Visits
sc Supplemental Classification
pm PMH
ps PSH
al ALLERGIES
as ASSESSMENT
General
NC Type, age, [(m/f)], b/e, title
no SOAP Note
su Subjective
fh FH
sh SH
rs ROS
ex EXAM
pl PLAN
Focused
NC Type, Dz Cat/body sys(- -), age(a/c), [gender(m/f)], b/e, title (subdirectory/title OR solely title)
no SOAP Note
su Subjective
fh FH
sh SH
rs ROS
ex EXAM
pl PLAN
al Comprehensive (All / Head to Toe)
co Constitutional
cv Cardiology / Circulatory System
de Dermatology / Skin, Subcutaneous Tissue
en Endocrine / Nutritional & Metabolic Disorders
gi Gastroenterology / Digestive System
gu Genitourinary System / Renal / Urology / Gynecology
he Hematology / Blood Diseases
id Infectious Disease / Parasitic Diseases
ne Neurology / Nervous System Disorders
ob Obstetrics / Pregnancy, Childbirth
on Oncology / Neoplasms
op Ophthalmology / Disorders of the Eyes
or Orthopedics / Musculoskeletal & Connective Tissue
ot Otolaryngology / Ears, Nose, and Throat
pd Pediatrics
ps Psychiatry / Mental Disorders
pu Pulmonology / Respiratory System
rh Rheumatology / Allergic and Immunologic Disorders
------
hm Prevention (Health Maintenance)
sc Supplemental Classification
ss Signs & Symptoms
2.
ROS
co Constitutional
de Integumentary
op Ophthalmologic
ot Otolaryngologic
cv Cardiovascular
pu Respiratory
gi Gastrointestinal
gu Genitourinary
Female -- Genitourinary
Female -- Gynecologic
Female -- Breasts
Female -- Obstetric
Male -- Genitourinary
Male -- Genital
or Musculoskeletal
ne Neurologic
ps Psychiatric
en Endocrine
he Hematologic/ Lymphatic
rh Allergic/ Immunologic
EXAMS
co Constitutional
de Integumentary
op Ophthalmologic
ot Otolaryngologic
cv Cardiovascular
pu Respiratory
ob Chest / Breasts
gi Gastrointestinal
gu Genitourinary
Female -- Genitourinary
Female -- Gynecologic
Female -- Obstetric
Male -- Genitourinary
Male -- Genital
or Musculoskeletal
General
Neck
Back
Shoulder
Elbow
Wrist
Hand
Hip
Knee
Ankle
Foot
ne Neurologic
ps Psychiatric