Using a friend, family member, or colleague, perform aHEENT, integumentary, and abdominal exam. Document the physical examination findings in the SOAP note format.
Even though your patient may have abnormal findings, you must document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings.The completesubjective and objectivesections must be included. You may include the assessment and plan portion of the SOAP note, but these sections will not be graded.
You should devise a chief complaint so that you may document the OLDCART (HPI) data.You must use the chief complaint of sinus congestion, rash, and abdominal pain.You should also focus the ROS based on the patient’s chief complaint and the body systems being examined.