SOAP NOTE 4/ GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS

Faculty Comments:  Faculty Comments: Points DescriptionSubjective5 Chief complaint stated in patient’s own words.10 HPI, PMH, PSH, Family History, Social Habits,10 Contains all systems relevant information to make assessment with normal and abnormal findings.20 Objective present and contains all pertinent objective information available (drug allergies, physical findings, drug list, etc)20 Assessment presents justification for Main or Primary diagnosis15 Assessment rules out other potential disorders5 Plan contains discussion of therapy options with pros and cons of each. Also10 Plan stated as directives (start, stop, non-pharmacologic and pharmacologic treatment etc)5 Plan include monitoring and follow upComments: please explain the3 differential dignosis in further notes

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