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
Congestive heart failure
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