This checklist guides providers in documenting patient information within SOAP (Subjective, Objective, Assessment, Plan) notes to meet insurance and treatment requirements. Key subjective items include chief complaints (must document CPAP intolerance), Epworth Sleepiness Scale score (must be 11+ for comorbidity), allergies, medications, and various histories. Objective requirements include sleep study results (AHI ≥ 5 with at least 1 comorbidity), vital signs, and various dental and airway examinations. The assessment section requires treatment candidacy, diagnosis with ICD code (G47.33 for OSA), and physical impressions status. The plan section mandates recommended services with CPT codes (e.g., E0486), treatment plan details, follow-up timeline, and patient education/consent discussion.

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Categories: Practice Packet