Develop a focused soap note for the abnormal finding

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Reference no: EM133409132

Develop a focused SOAP note for the abnormal finding of chest pain. You do not need to find a patient to match this finding. In other words, develop a patient scenario and document it in SOAP format. Please be sure to include all relevant information and not just the system the abnormal finding is in. use format below

Information about the patient (3 points)

Name (initials only); age, and gender
Source of information; note relationship to patient, if relevant
Reliability of information
Chief Complaint:

History of Presenting Illness

Location
Quality
Quantity or severity
Timing (onset, duration, frequency)
Setting in which it occurs
Factors that aggravate or relieve the symptoms
Associated manifestations
Review of Focus System(s) (5 points)

Medications/Allergies (3 points)

History

Past Medical History
Past Surgical History
Family History
Social History
Health Maintenance Practices
Objective

Physical exam includes appropriate areas for Chief Complaint, History of Presenting Illness, and Review of Systems

Appropriate techniques of examination used to identify pertinent findings.

Differential diagnoses are supported by subjective and objective findings

Scholarly resources support differential diagnoses.

Plan:

Documentation

Documentation follows SOAP template, is logical, and in correct format

Comprehensive plan to address likely differential diagnosis includes:

Diagnostic testing
Pharmacologic intervention
Non-pharmacologic intervention
Referrals
Patient education
Follow-up
Plan is supported by appropriate and current practice guidelines.

Reference no: EM133409132

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