- Analyze the subjective portion of the note. List additional information that should be included in the documentation.
- Analyze the objective portion of the note. List additional information that should be included in the documentation.
- Is the assessment supported by the subjective and objective information? Why or why not?
- Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
- Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.