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Chest Pain Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:

  1. Location
  2. Quality
  3. Quantity or severity
  4. Timing, including onset, duration, and frequency
  5. Setting in which it occurs
  6. Factors that have aggravated or relieved the symptom
  7. Associated manifestations

: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.

Sample Solution

e best use of the SWOT analysis it is essentials to understand de Gaulle and in this paper, the focus is 1940 – 1960. This is still a wide-ranging period of time with many of events taking place. However, there are two key events in which the paper will centre on. The first is when de Gaulle was the leaders of the Free French Army towards the end of WWII, and secondly when he was invited back to power in 1958 to tackle the on-going Algerian war and the creation of the 5th Republic. The question is centered on leadership theories. Understanding what is meant by leadership and its definition is an integral aspect of the paper and answering the question. Definition of Leadership Understanding the definition of leadership provides a metric to measure de Gaulle’s success against. There are almost as many different definitions of leadership as there are persons who have attempted to define the concept . The following components can be identified as central to the phenomenon, Leadership is a process, and it involves influence, occurs in a group context and involves goal attainment. Based on Northouse theory this paper will use his definition to define leadership . “Leadership is a process whereby an individual influence a group of individuals to achieve a common goal” . The definition provides key verbs. It states leadership is a process and therefore a series of steps or actions in order to achieve a particular end. The particular end in leadership term is a common goal. Common goals are key to influencing a group of individuals. Goals can be set in many different ways, one of the most common is a clear vision. The group must believe in what they are trying to achieve, without this belief they are unlikely to follow. One complex definition that has evolved, particularly to help understand a wide variety of research findings, delineates effective leadership as the interaction among members of a group that initiates and maintains improved expectations and the competence of the group to solve problems or to attain goals . There are a number of commonalities when comparing both definitions, both refer to groups and goal attainment. This would lead to the deduction that good leadership requires influence to achieve an end state, whether short term goals, long term vision or political and national identities, which is the case with d
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