Hi. I need the revision of  a SOAP Note.

– The history of present illness (HPI) Subjective and objective is mixed. HPI is part of the subjective.

  • – Exacerbating factor is missing
  • – Differential diagnosis:” Gallstone” – Is it not better Acute Cholecystitis? 
  • – Check the rational for each diagnostic.
  • – Diagnostic test and results.
  • –  Plan of care:  This is a patient that went to a family doctor with abdominal pain. I need to specify what was done for the patient, not as MAY. What was prescribed? Medication, dose, frequency, and duration. What side effects might she experience, what was she told? What education was provided to her? When is her follow up?
  • – Check the reflection part.
  • – Be sure to use correct APA 7 edition formatting.
  • – References: I am required to have at least 3 evidence-based peer reviewed journal articles.

 

This case study was created by one of your writers, but still have some mistakes I need to fix. Thanks

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