Review the DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Consider what history would be necessary to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes is detailed and organized and includes:
Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)
ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
General: Head: EENT: etc.
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