soap note write up

Physical Exam Write Up: below is the grading criteria. Just choose a patient with past med hx of hypertension and diabetes who just visited for a complete annual physical assessment.

please do intext reference in your diagnosis section.

i will attach a soap note template

Logical and clear components per body system 10 points

information flows well and succinct 5 points

Information documented contributes directly to assessment video findings 5 points

Negative Exam findings were documented; no important information left out 5 points

Lists all active medical conditions 5 points

Records date of onset of medical conditions 5 points

Diagrams or precise measurements included 5 points

Correct spelling, grammar, and medical terminology 5 points

Professional tone and writing 5 points

 

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