Documentation Notes

Documentation Notes - (Paragraph P Recommend Low sodium and...

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Documentation Notes ADI: A:  Assessment (Paragraph form) D:  Diagnosis (PES Statement) I:  Intervention (Plan)- Bullets SOAP: S:  Subjective- What the patient told you “Patient Reports…”- Paragraph Form O:  Objective- Lab Values: Cholesterol, LDL, HDL, Anthropometrics, Ht, Wt, BMI, %IBW,  %UBW, Physical Exam, Medications (List)- Prednisone  A:  Assessment – Patient needs low sodium, NCS diet due to prednisone medications 
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Unformatted text preview: (Paragraph) P: Recommend Low sodium and NCS (List) ENERY NEEDS = O or A SOAP & ADI ASSESSMENT: CHRONIC DISEASE RISK-Assess weight- BMI-Assess Labs--Dietary recall-Explain your plan *In assessment- use the book and write the page numbers – At least 2...
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