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High Workload note (faster SOAP)
Dec 21, 2024
•
Mark Morgan
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CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
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PAST MEDICAL HISTORY:
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REVIEW OF SYSTEMS:
As above in HPI. Other pertinent constitutional symptoms, HEENT symptoms, cardiac symptoms, respiratory symptoms, gastrointestinal symptoms reviewed and negative
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ALLERGIES:
MEDICATIONS:
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PHYSICAL EXAM:
VITALS: GENERAL: alert, no distress HEENT: oropharynx clear RESPIRATORY: Clear to auscultation bilaterally. CV: Regular rate and rhythm. ABDOMEN: Bowel sounds normal. soft. SKIN: No rashes NEURO: Strength 5/5 at upper and lower extremities. Gait normal.
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ASSESSMENT/PLAN:
orders reviewed appropriate follow up discussed - before last refill, sooner if s/s worsen or new s/s appear.
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