Instructions:
Read the attached SOAP note about “J.H.” He recently moved to the area and is at your family practice clinic to establish care with a new provider – YOU! (File attached as SOAP Assignment 1)
Answer the questions on a separate Word document. Use the Documentation Guide for Chronic Conditions Download Documentation Guide for Chronic Conditions (Template attached ) as a guide and USE THIS FORMAT.
Grading Rubrics will be attached as well.
Objectives:
Identify components of system-based physical examinations.
Critique SOAP notes for missing history elements.
Identify the pathophysiology of an identified disease process and its relationship to assessment findings for individual patients.
Differentiate pertinent findings in a patient’s health history and physical examination.
Identify sources for clinical decision-making for use in the assessment of patients.
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