SOAP Report Format - Official Miami Dade College …

General appearance of the patient, how patient was found, vital signs (pulse, respirations, BP, SaO2, glucose reading), complete head-to-toe assessment. (A)ssessment: Your evaluation or assessment of what is wrong with the patient. YOU DO NOT DIAGNOSE. Examples include: Possible MI, Neck pain secondary to MVA, SOB of unknown etiology.

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