Congestive heart failure

SOAP note with template. The SoAP note should be complete about a 54 year old man never diagnosised prior with CHF . Brought in by his wife for shortness of breath. Weight gain of 6lbs duration of 4 days with the last 2 days getting worse. No medications because he has never been ill. He has suffered from headaches from time to time. CC weed eating his yard 4 days ago when he got a tightness in his chest and SOB. Grade rubric

Complete Subjective Information
PMH, PSH, FH, ROS completed. Provide complete and concise summary of pertinent information.	2
Complete Objective Information
Complete physical exam with critical elements related to subjective data.	2
Perform Assessment
Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.	2
Create a Plan
Plan includes pharmacologic and nonpharmacologic treatments as well as education provided. The plan is supported by evidence/guidelines, and the follow-up plans are noted.	2
Self Assessment & Clinical Guidelines
Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.	2
Total:	10

Remember an use ICD – 10 for each differential diagnosis including diagnosis. An support with patient info and findings which is subject and objective findings

Answer Preview…………….

Name: John Doe	Pt. Encounter Number:
Date: 9 May 2017	Age: 54	Sex: Male
SUBJECTIVE
CC: Reason given by the patient for seeking medical care “in quotes” “Patient complained tightness in his chest and short of breath”
HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness. John Doe’s condition began four days while weeding his yards for four days ago as he experienced tightness in his chest and shortness of breath. Two days after the onset of the symptoms, the patient had gained 6lbs extra weight and developed no other symptoms aside from the constant headaches he experienced from time to time. ,……….

APA 1099 words