Complete Congestive Heart Failure SOAP Note.
Encounter date: ________________________
SOAP Adult
Patient Initials: __________ Gender: Male____ Female___ Transgender ____ Age: _____
Race: __________________
Chief Complaint: ________________________________________________________________
HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies (Drug/Food/Environmental/Herbal):____________________________________________________________________________________________________________________________________________________________________________________________________________ Current perception of Health: Excellent Good Fair Poor
PMH: ________________________________________________________________________
PSH: ________________________________________________________________________
Hospitalizations: ______________________________________________________________
Current Meds: ______________________________________________________________
Family History:_______________________________________________________________
Social history: __Married __Widowed __Single __ Divorced __Cohabitating Partner
Lives: __Home __Alone __ Family __Caretaker __ACLF __ SNF ___Other:
Smoke: ______________ETOH: ________________ Recreational Drug Use: _____________
Immunization HX: Please Document Date of Immunization or Date of Disease.
| Immunizations | Pneumovac | HPV | HEP B | MMR | Varicella | TD/Tdap | FLU | Other: |
| DATE:_____ | DATE:___ | 1. | 1. | 1. | ||||
| 2. | 2. | 2. | ||||||
| 3. | ||||||||
| Disease |
Review of Systems:
General_______________________________________________________________________
HEENT_______________________________________________________________________
Neck________________________________________________________________________
Lungs ________________________________________________________________________
Cardiovascular ________________________________________________________________
Breast ________________________________________________________________________
GI ___________________________________________________________________________
Male/female genital _____________________________________________________________
GU __________________________________________________________________________
Neuro_________________________________________________________________________
Musculoskeletal________________________________________________________________
Activity & Exercise _____________________________________________________________
Psychosocial ___________________________________________________________________
Derm_________________________________________________________________________
Nutrition ______________________________________________________________________
Sleep/Rest ____________________________________________________________________
LMP_____________
Physical Exam
BP__________TPR_______ ________Ht. ________ Wt. _________________ Wt. Change____ BMI_____________ O2 SAT%__________________
General_______________________________________________________________________
HEENT_______________________________________________________________________
Neck_________________________________________________________________________
Pulmonary_____________________________________________________________________
Cardiovascular_________________________________________________________________
Breast________________________________________________________________________
Abdomen______________________________________________________________________
Rectal________________________________________________________________________
Male/female genital_____________________________________________________________
Musculoskeletal________________________________________________________________
Neuro_________________________________________________________________________
Derm_________________________________________________________________________
Psych_________________________________________________________________________
Misc._________________________________________________________________________
Assessment:
Significant Data/Contributing Dx/Labs/Misc
Differential Diagnoses
1.
2.
3.
Diagnoses
1.
2.
3.
Plan
Diagnosis # 1
Diagnostic:
Therapeutic:
Educative:
Referrals:
Follow-up:
Diagnosis # 2
Diagnostic:
Therapeutic:
Educative:
Referrals:
Follow-up:
Diagnosis # 3
Diagnostic:
Therapeutic:
Educative:
Referrals:
Follow-up:
Signature_____________________________________________________________________
Cite current evidenced based guideline(s) used to guide careMandatory)
1._____________________________________________________________________
DEA#: 101010101 Barry University LIC# 1010101010101
College of Nursing Clinic
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age _______________
Address: ________________________________________ Allergies: _____________________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: ____________________________________________________________
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