4Worksheet 3

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Chatham University *

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MISC

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Mechanical Engineering

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Apr 3, 2024

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docx

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Worksheet 3.4 Name SOAP Note Analysis: A. W. Here is a SOAP note for patient A. W. who presented to an urgent care center with complaints of nausea and vomiting. She has not been seen at this urgent care before. The SOAP note was written by Jason Wilson, a physician assistant student who is on a rotation at the urgent care center. Please read the note and answer the questions that follow. 1.Analyze the Subjective portion of the note. List additional information that should be included in the documentation. 2.Analyze the Objective portion of the note. List additional information that should be included in the documentation. 3.Is the assessment supported by the subjective and objective information? Why or why not? 4.Did you consider differential diagnoses other than the ones documented? If so, list.
5.What condition/symptom/diagnosis would be most appropriate to document for this visit? Can you find an ICD-10 code for it? 6.Does the plan correspond to the assessment? Why or why not? 7.Did you consider other interventions that could be included in the plan? If so, list.
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