Internal Medicine Soap Note
SOAP Note
Prepared by Sherri R. Williams, Fusion Edge Technologies
Introduction
The SOAP note herein is a comprehensive documentation of the diagnosis and sessions summary for patient James Young, a 39-year-old male, standing at 5'10" and weighing 170 lbs. This note is constructed against the standard method of documentation in Internal Medicine which encapsulates four main aspects: Subjective, Objective, Assessment, and Plan (SOAP).
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Subjective |
Objective |
Assessment |
Plan |
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The patient's symptoms of fatigue, headaches, and shortness of breath suggest probable hypertension. Further diagnostic tests required to confirm such suspicions. |
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