• medgremlin
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    3 hours ago

    You have to be very careful about “filtering” as well. It becomes far too easy to write off a legitimate concern if it has to pass muster with your “filter” before you consider it. The HPI and subjective portions of a note are explicitly for the things the patient (or their caretaker) tells you. It is subjective. Then you do your objective examination and testing, then you make an assessment, and if you can justify that assessment with the testing and history, then you can make a plan. SOAP notes go in that order for a reason.