Diagnostic
reasoning/
SOAP note
K U A N G I ( G R A C E ) H U A N G ,
M S N , A P R N , F N P - C
C L I N I C A L A S S I S T A N T
P R O F E S S O R
E M A I L : K U A N G I . H U A N G @ U T
A . E D U
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Diagnostic Reasoning Case Study while Using an EHR [EHR Go, which is an academic EHR]
Typology: Papers
2025/2026
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Diagnostic
reasoning/
SOAP note
K U A N G I ( G R A C E ) H U A N G , M S N , A P R N , F N P - C C L I N I C A L A S S I S T A N T P R O F E S S O R E M A I L : K U A N G I. H U A N G @ U T A. E D U
What is a
progress note
(SOAP note)
- (^) Purpose: as evidence of patient encounter
- (^) Documentation of patient’s clinical problems, progress and treatment plans
- (^) Communicate with colleagues about the care we have rendered
- (^) Subjective information, Objective information, Assessment, Plan
- (^) The SOAP note provides a cognitive framework for clinical reasoning, guiding healthcare providers in using the information provided to assess, diagnose, and treat a patient.
- (^) You will learn in clinical course
What are examples of differential
diagnoses?
- (^) Abdominal pain: ache, cramps or sharp pains at mild to severe levels localized to a specific area in your stomach region
- (^) Appendicitis.
- (^) Gastritis.
- (^) Inflammatory bowel disease.
- (^) Intestinal or bowel blockage.
- (^) Pancreatitis.
- (^) Chest pain: aching, sharp pain, burning sensations, tightness or squeezing pressure localized in the chest
- (^) Angina.
- (^) Anxiety.
- (^) Muscle strain.
- (^) Pneumonia.
- (^) Viral infection.
- (^) Fatigue: feeling tired, lack of energy, not getting enough sleep and feeling weak throughout your entire body.
- (^) Anemia.
- (^) Depression.
- (^) Insomnia.
- (^) Thyroid disease.
Diagnostic
evaluation
- (^) Ask questions about the symptoms.
- (^) Review medical history.
- (^) Perform a physical examination.
- (^) Create differential diagnoses.
- (^) Order additional tests to confirm a diagnosis:
- (^) Laboratory tests (blood or urine). Imaging tests like an X-ray, ultrasound, biopsy.
- (^) Reviewing test results and symptoms.
- (^) Make a final diagnosis and recommend treatment.