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 separate 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/diagnoses 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
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