primary care setting

primary care setting

· For your note this week, create an HEENT related CC. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least 3 differential diagnoses, a final diagnosis, and treatment plan in a full SOAP note format. Use an HEENT related CC that a patient would present with in a primary care setting (i.e. no emergency room or ICU type complaints. Examples: sore throat, ear ache, hearing loss, eye drainage, etc.).

· Include at least two references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer-reviewed. Use APA title page, citations, and reference format. Ensure the treatment plan includes all components (diagnostic plan, therapeutic plan, education plan, and follow up).

· The ROS and physical exam in your document should be written up as they would be for a problem focused visit. The HEENT part of the physical exam write up should be a comprehensive write up.