Document the history and the expected normal physical examination findings in the SOAP note format of detailed women's health history Even though your patient may have abnormal findings, you must 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 may include the assessment and plan portion of the SOAP note, but these sections will not be graded.
You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of burning while urinating, irregular menstrual cycle, or pelvic pain. You should also focus the ROS based on the patient's chief complaint and the body systems being examined.
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