SOAP NOTE 6 CHALAZION RIGHT UPPER EYELID
Faculty Comments: Faculty Comments: Points Description
5 Chief complaint stated in patient’s own words.
10 HPI, PMH, PSH, Family History, Social Habits,
10 Contains all systems relevant information to make assessment with normal and abnormal findings.
20 Objective present and contains all pertinent objective information available (drug allergies, physical findings, drug list, etc)
20 Assessment presents justification for Main or Primary diagnosis
15 Assessment rules out other potential disorders
5 Plan contains discussion of therapy options with pros and cons of each. Also
10 Plan stated as directives (start, stop, non-pharmacologic and pharmacologic treatment etc)
5 Plan include monitoring and follow up
NOTE: please explain 3 differential dignosis !!