- Identify a patient in the clinical setting or friend, peer, or family member who you can interview for a comprehensive health history as though they were a new patient to your office.
- Conduct an interview and document the comprehensive health history and subjective review of systems.
please note : References are only needed for the assessment and plan components of the SOAP note. Also, NEVER use general, patient-focused sites such as Mayoclinic.com, clevelandclinic.com etc.
Work to integrate the HPI data into a concise paragraph.
Each system must be addressed.
be very precise with your documentation and avoid vague terms
Work to integrate the HPI data into a concise paragraph