My C.I is an inconsiderate biatch who doesn't want to teach me how to make one just because I was absent on the day she taught it, even though I have an excuse letter. Please, please, please help me I am desperate.
I assume you are referring to SOAP notes to record your medical finding.
S: Subjective - write down what the patient tells you; concentrating on the reason why the patient is sick
O: Objective - write down the vitals, the physical exam findings
A: Assessment - what you think might be wrong with this patient, including his most likely diagnosis as well as past relevant diagnoses
P: Plan - what you are going to do to take care of the possible diagnosis, including labs, tests, medication, etc.
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