Writing a medical assessment and plan
History and physical examination (h&p) examples
Dosage, frequency and adherence should be noted. However, it is obviously of great importance to include all of the past cardiac information "up front" so that the reader can accurately interpret the patient's new symptom complex. Rivkin A. This represented a significant change in his anginal pattern, which is normally characterized as mild discomfort which occurs after walking vigorously for 8 or 9 blocks. He denies fevers, chills, cough, wheezing, nausea vomiting, recent travel, or sick contacts. Obstetrical History where appropriate : Included the number of pregnancies, live births, duration of pregnancies, complications. Acta Med Port. Work History: type, duration, exposures. S is a 70 yr old male presenting with chest pain who has the following coronary artery disease related history: -Status Post 3 vessel CABG in The more succinct yet thorough a SOAP note is, the easier it is for clinicians to follow. Unless this has been a dominant problem, requiring extensive evaluation, as might occur in the setting of secondary hypertension. Dolan R, Broadbent P. Assessment of SOAP note evaluation tools in colleges and schools of pharmacy. Example: Problem 1, Differential Diagnoses, Discussion, Plan for problem 1 described in the plan below.
While a Chest X-Ray and smoking history offer important supporting data, they are not diagnostic. Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology.
Writing HPIs for patients with pre-existing illness es or a chronic, relapsing problems is a bit trickier. These comments are referred to as "pertinent positives. Your residents can assist you.
The remainder of the HPI is dedicated to the further description of the presenting concern. All other historical information should be listed.
It also addresses any additional steps being taken to treat the patient.
based on 55 review