Work out;
a) Appropriate systems are examined, listed in the note and
consistent with those identified in 2b.
b) Pertinent positives and negatives must be documented for
each relevant system.
c) Any abnormalities must be fully described. Measure and
record sizes of things (likes moles, scars). Avoid using ‘ok”,
-clear, “within normal limits”. positive/ negative. and
normal/abnormal to describe things.
4) Assessment: Diagnoses should be clearly listed and worded
appropriately.
5) Plan: Be sure to include any teaching, health maintenance,
and counseling along with the pharmacological and
non-pharmacological measures. If you have more than one diagnosis,
it is helpful to have this section divided into separately numbered
sections.
6) Subjective/ Objective. Assessment and Management and
Consistent: Does the note support the appropriate differential
diagnosis process? Is there evidence that you know what systems and
what symptoms go with which complaints? The assessment/diagnosis
should be consistent with the subjective section and then the
assessment and plan. The management should be consistent with the
assessment/ diagnoses identified. 7) Clarity of the Write-up: Is it
literate. organized and complete
Sample Solution
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