The progress note of Amy Shaw states that she is a 51-year-old female who has a history of lower back pain following a fall off a ladder in 2007. She has been taking ibuprofen on a daily basis with no relief. The pain is so bad that on occasion she needs to miss work. Based on her history and the results of the physician's physical exam, his treatment plan is naproxen sodium daily and an order for physical therapy to include TENS treatments with follow-up visit scheduled in four weeks. This is an example of a patient's health
Soap? Situation, objective, assessment, & plan for treatment, for the patient's chief complaint.