Gastrointestinal system ( diagnosis could be GERD)

A soap note example is downloaded. This is a general example, the assignment requires a soap note with a patient that has a lymphatic system problem. A reflection on the encounter should also be included. Thanks

Keep it simple.
One complaint.
Do not write WNL or Normal (WNL to me means “We Never Looked”: you are novices, describe what the throat looks like)
Your Subjective Data is only what the patient reports…it is not where you place your evaluations
The Objective data is what you observe: not what the patient reports
Any lab values (Rapid Strep Test, Urinalysis, etc) should be placed with the results in the Objective Data because that helps you decide your diagnosis
Assessment: Is Your Diagnosis (Include ICD 10)
You will then provide 3 Differential Diagnoses (diagnoses that it could be if your Primary is not correct) (Include ICD 10)
Your Differential Diagnoses Cannot be your Actual Diagnosis

Sample Solution