![]() ![]() The order in which medical notes are written has been a topic of discussion. A thorough note should include the possibility of other diagnoses that may harm the patient, but are less likely. This section explains the decision-making process in depth. It presents a list of possible diagnoses, from most to least likely, along with the thought process behind this ranking. The problem list is prioritized by importance. This assessment documents the patient's status through analysis of problems, potential interactions between them, and changes in their status over time. The synthesis of "subjective" and "objective" evidence is used to arrive at a diagnosis, distinguishing between symptoms and signs. Subjective evidence includes patients' self-reported symptoms, such as "stomach pain," which should be documented under the subjective heading. Objective evidence, on the other hand, refers to findings that can be observed or measured by the healthcare provider, such as "abdominal tenderness to palpation," which is documented under the objective heading. ![]() It is essential to recognize and review documentation from other clinicians involved in the patient's care. A common mistake is failing to distinguish between symptoms and signs, leading to inaccurate diagnosis and treatment.
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