The Progress Note

The Progress Note

The Progress Note Appropriately named, the progress note details the patient’s condition and how it has changed since the most recent documentation.  This note is generally brief.  Comprehensive assessment…

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Chest Pain: Lub dub and more

Chest Pain: Lub dub and more

Chest Pain: Lub dub and more This is one of the most feared chief complaints by patients and providers alike.  The differential diagnosis for this complaint includes myocardial infarction,…

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The SOAP Note – Subjective

The SOAP Note – Subjective

The SOAP Note – Subjective The structure of the SOAP note is emphasized in its name.  It stands for subjective, objective, assessment and plan.  The SOAP note format has…

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The Annual Physical

The Annual Physical

The Annual Physical Sometimes called the “wellness physical”, this encounter is a time to focus on the big picture.  It is a time to step back and consider the…

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