The differential is pertinent to signs and symptoms, the formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5.
Subjective Data: The Chief Complaint is clear, concise, and verbatim from pt. History of Present Illness is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (OLDCARTS) to validate Dx per DSM-5 TR criteria. All pertinent negatives are included. A longitudinal course of illness is clear. Current … Read more