Worksheet 3.6
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Apr 3, 2024
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Worksheet 3.6
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SOAP Note Analysis: C.F.
The SOAP note on page 71 is for patient C. F. who presented to an internal medicine office with complaints of abdominal pain. She has been seen at this office before, although not by this provider. She is seen by Malia Yazzi, Physician Assistant, who writes the SOAP note. 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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