All subjective data is present and clearly stated. Includes age, gender, race, c

All subjective data is present and clearly stated. Includes age, gender, race, chief complaint, Past medical history, medications, History of present illness. Detail of each included.
All objective data is present including: general appearance/behavior, vital signs, physical exam, and your general impression of patient
Assessment is clear with conclusions based on subjective and objective data & probable diagnosis is listed
Plan of action is clearly stated with any follow-up or referrals noted

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