This is where the decision-making process is explained in depth. This is a list of the different possible diagnosis, from most to least likely, and the thought process behind this list. List the problem list in order of importance.
This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems. This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. Versus “abdominal tenderness to palpation,” an objective sign documented under the objective heading. An example of this is a patient stating he has “stomach pain,” which is a symptom, documented under the subjective heading. Symptoms are the patient's subjective description and should be documented under the subjective heading, while a sign is an objective finding related to the associated symptom reported by the patient.
Recognition and review of the documentation of other clinicians.Ī common mistake is distinguishing between symptoms and signs.
