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From SOAP to SNOCAMP

 

What is SNOCAMP?

SNOCAMP is a medical records format that includes the same four elements of SOAP with the addition of

  1. Nature of Illness (hi/ med/ low severity)

  2. Counseling

  3. Medical Decision Making (hi/ med/ low complexity)

FROM:

TO:  

Subjective

Subjective

 

Nature of Illness (hi/med/low severity)

Objective

Objective

 

Counseling

Assessment

Assessment

 

Medical Decision Making (hi/med/low complexity)

Plan

Plan

The advent of third-party audits, malpractice attorney subpoenas, medical guidelines and reimbursement code criteria all require comprehensive, readable documentation. We highly recommend this expanded format.

SNOCAMP, in conjuction with proper physician training, a coding compliance plan and a trained coding and medical transcription staff, will ensure better documentation, better medicine and a better chance of passing a documentation audit.

SNOCAMP was developed in 1992, by Walter I. Larimore, MD. This format assists in assigning the correct Evaluation and Management (E & M) code.

The categories are defined as follows:

Subjective: Chief complaint, HPI, System Review and Past, Social and Family History.

Nature of Presenting Problem: describes the complexity or severity of the patient’s chief complaint, a disease, condition illness, injury symptom, sign, finding or other reason for the encounter.

Objective: Review of Systems (denies loss of weight, headaches, chest pain, etc...) 

Counseling: Think of PAR, Procedures, Alternatives and Risks; list start and end times, detail the nature of the counseling or coordination of activities.

Assessment: What is the diagnosis or differential diagnosis? What are the potential complications?

Medical Decision Making

  1. Number of Diagnoses or Management Options

  2. Amount and/or complexity of Data to be reviewed

  3. Risk of Complications and/or morbidity or mortality

  4. Complexity of Decision-Making

This must be based on the information documented in the counseling, assessment and plan components of the medical record.

Plan: Treatment options should include rationale for any changes in treatment or tests ordered.

SNOCAMP an example:

S

Patient complains of sneezing, itchy/watery eyes

N

Low Severity

O

HEENT: Bilateral conjunctial cobblestoning with minimal erythema and no discharge. PERL: EOMs intact. Nasal turbinates bogy. Pharynx and ears n.

C

Discussed diagnostic impression, risks/benefits of mgmt options with patient

A

1. Allergic rhinitis.

 

2. Allergic conjunctivitis

M

Take over the counter antihistamine, drink plenty of fluids (Straightforward)

P

1. Pleph-10 Ophthalmic Solution, 2 dp ou quid x 5 d.

 

2. Claritin-D, 1 po bid prn (#30 ~ NR, but may call for refill of #30 x prn).

 

3. Follow-up prn.

 
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