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Documentation Quality Score
94%SOAP Note
Subjective 95% confidence
Patient reports chest pain starting 2 hours ago, radiating to left arm. Rates pain 7/10. No shortness of breath. History of hypertension.
Objective 90% confidence
BP 145/92, HR 88, RR 16, SpO2 98% RA. Alert and oriented. Chest wall non-tender. No edema. ECG shows normal sinus rhythm.
Assessment 88% confidence
1. Acute chest pain - possible ACS vs musculoskeletal vs anxiety
2. Hypertension, uncontrolled
3. History of CAD
Plan 92% confidence
1. Stat ECG and troponin I
2. Chest X-ray PA & lateral
3. ASA 325mg chewable (if not allergic)
4. NTG 0.4mg SL q5min x3 PRN
5. Cardiology consult if indicated
6. Admit to observation unit pending results
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Subjective
Patient reports chest pain starting 2 hours ago...
Objective
BP 145/92, HR 88, ECG normal sinus...
Assessment & Plan
ACS ruled out, hypertension management...
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