Using a friend, family member, or co-worker:
Neurovascular (include all cranial nerves), musculoskeletal, and cardiopulmonary (includes the heart, lungs, and peripheral vasculature) exam.
Document the physical examination findings in the SOAP note format.
Have abnormal findings, document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings. The complete subjective and objective sections must be included.
You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of headache, back pain, and cough. You should also focus the ROS based on the patient's chief complaint and the body systems being examined.