In the SOAP Note I need to have the patient with two chief complaints. 1st chief complaint focusing on neuro issue and 2nd chief complaint focusing on musculoskeletal issue. Remember to include HPI and ROS that are pertinent to your chief complaints. Objective/Physical exam also pertinent to your chief complaint. Use SOAP NOTE format please and APA reference documentation.
Perform a complete neurologic and musculoskeletal examination on your patient. Document your findings for a “normal” examination for both the neurologic and musculoskeletal systems using the SOAP note format.
You should document the expected normal exam findings for the system. The complete subjective and objective sections should be included. If there is no chief complaint, you should devise a complaint to complete the HPI and OLDCART portion of the note. It is not necessary to complete the assessment and plan section of the SOAP note for this discussion.
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