SOAP Note Cardiovascular

About Congestive Heart Failure

PRIMARY

CARE SOAP NOTE

Student:

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Date:

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Professor: ______________________________________________________________

PATIENT INFORMATION:

NAME:

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AGE:

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SEX:

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CC:__

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SUBJECTIVE:

HPI:_________________________________________________________________________
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PRIMARY CARE SOAP NOTE

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ALLERGIES:

CURRENTMEDICATIONS_____________________________________________________

PMHX:_______________________________________________________________________

FAMH:_______________________________________________________________________

SOCHX:______________________________________________________________________

PRIMARY CARE SOAP NOTE

REVIEW OF SYSTEMS:

CONSTITUTIONAL:__________________________________________________________

HEENT:

HEAD:_______________________________________________________________________

EYES:________________________________________________________________________

EARS:_______________________________________________________________________

NOSE:_______________________________________________________________________

THROAT:____________________________________________________________________

RESPIRATORY:

PRIMARY CARE SOAP NOTE

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CARDIOVASCULAR__________________________________________________________

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL: _______________________________________________________

NEUROLOGIC:_______________________________________________________________

PRIMARY CARE SOAP NOTE

OBJECTIVE:

CONSTITUTIONAL:

SKIN:

NECK:

______________________________________________________________________________

RESPIRATORY:

PRIMARY CARE SOAP NOTE

CARDIOVASCULAR:

GASTROINTESTINAL:

PRIMARY CARE SOAP NOTE

GENITOURINARY:

PERIPHERAL VASCULAR:

MUSCULOSKELETAL:

NEUROLOGIC:

PRIMARY CARE SOAP NOTE

ASSESSMENT:

DIAGNOSIS:

DIFFERENTIAL DIAGNOSIS:

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PRIMARY CARE SOAP NOTE

PLAN:

Non-

Pharmacologic treatment:

PRIMARY CARE SOAP NOTE

Pharmacologic treatment:

MEDICATIONS:

FOLLOW-UPS/REFERRALS:

RATIONALE:

PRIMARY CARE SOAP NOTE

CC
1:
CC
2:
CC
3:
CC
4:
HPI 1:
HPI 2:
HPI 3:
HPI 4:
HPI
5:
HPI
6:
HPI
7:
HPI
8:
HPI
9:
HPI
10:
HPI
11:
HPI
12:
HPI 13:
HPI 14:
HPI 15:
HPI 16:
HPI 17:
HPI 18:
HPI 19:
HPI 20:
HPI 21:
HPI 22:
HPI 23:
HPI 24:

1:
2:
3:
4:

ALLERGIES 1:
ALLERGIES 2:
ALLERGIES 3:
ALLERGIES 4:
CURRENT
MEDICATIONS 1:
CURRENT
MEDICATIONS 2:
CURRENT
MEDICATIONS 3:
CURRENT
MEDICATIONS 4:
PMHX 1:
PMHX 2:
PMHX 3:
PMHX 4:
FAMH 1:
FAMH 2:
FAMH 3:
FAMH 4:
FAMH 5:
SOCHX 1:
SOCHX 2:
SOCHX 3:
SOCHX 4:
CONSTITUTIONAL 1:
CONSTITUTIONAL 2:
CONSTITUTIONAL 3:
CONSTITUTIONAL 4:
HEAD 1:
HEAD 2:
HEAD 3:
HEAD 4:
EYES 1:
EYES 2:
EYES 3:
EARS 1:
EARS 2:
EARS 3:
NOSE 1:
NOSE 2:
NOSE 3:
THROAT 1:
THROAT 2:
THROAT 3:
THROAT 4:
RESPIRATORY 1:
RESPIRATORY 2:
RESPIRATORY 3:
RESPIRATORY 4:
CARDIOVASCULAR 1:
CARDIOVASCULAR 2:
CARDIOVASCULAR 3:
CARDIOVASCULAR 4:
CARDIOVASCULAR 5:
CARDIOVASCULAR 6:
GASTROINTESTINAL 1:
GASTROINTESTINAL 2:
GASTROINTESTINAL 3:
GASTROINTESTINAL 4:
GASTROINTESTINAL 5:
GASTROINTESTINAL 6:
GENITOURINARY 1:
GENITOURINARY 2:
GENITOURINARY 3:
GENITOURINARY 4:
GENITOURINARY 5:
MUSCULOSKELETAL 1:
MUSCULOSKELETAL 2:
MUSCULOSKELETAL 3:
MUSCULOSKELETAL 4:
NEUROLOGIC 1:
NEUROLOGIC 2:
NEUROLOGIC 3:
NEUROLOGIC 4:
NEUROLOGIC 5:
NEUROLOGIC 6:
CONSTITUTIONAL
1_2:
CONSTITUTIONAL
2_2:
CONSTITUTIONAL
3_2:
CONSTITUTIONAL
4_2:
SKIN 1:
SKIN 2:
SKIN 3:
SKIN 4:
HEENT 1:
HEENT 2:
HEENT 3:
HEENT 4:
HEENT 5:
HEENT 6:
HEENT 7:
HEENT 8:
HEENT 9:
HEENT 10:
HEENT 11:
HEENT 12:
HEENT 13:
HEENT 14:
NECK 1:
NECK 2:
NECK 3:
NECK 4:
NECK 5:
RESPIRATORY 1_2:
RESPIRATORY 2_2:
RESPIRATORY 3_2:
RESPIRATORY 4_2:
RESPIRATORY 5:

1_2:
2_2:
3_2:
4_2:
5:
6:
7:
8:
9:
10:
11:
12:

CARDIOVASCULAR 1_2:
CARDIOVASCULAR 2_2:
CARDIOVASCULAR 3_2:
CARDIOVASCULAR 4_2:
CARDIOVASCULAR
5_2:
CARDIOVASCULAR 6_2:
CARDIOVASCULAR 7:
CARDIOVASCULAR 8:
CARDIOVASCULAR 9:
CARDIOVASCULAR 10:
CARDIOVASCULAR 11:
CARDIOVASCULAR 12:
GASTROINTESTINAL 1_2:
GASTROINTESTINAL 2_2:
GASTROINTESTINAL 3_2:
GASTROINTESTINAL 4_2:
GASTROINTESTINAL 5_2:
GASTROINTESTINAL 6_2:
GASTROINTESTINAL 7:
GASTROINTESTINAL 8:
GASTROINTESTINAL 9:
GASTROINTESTINAL 10:
GASTROINTESTINAL 11:
GENITOURINARY 1_2:
GENITOURINARY 2_2:
GENITOURINARY 3_2:
GENITOURINARY 4_2:
GENITOURINARY 5_2:
GENITOURINARY 6:
GENITOURINARY 7:
GENITOURINARY 8:
GENITOURINARY 9:
GENITOURINARY 10:
GENITOURINARY 11:
GENITOURINARY 12:
PERIPHERAL VASCULAR 1:
PERIPHERAL VASCULAR 2:
PERIPHERAL VASCULAR 3:
PERIPHERAL VASCULAR 4:
PERIPHERAL VASCULAR 5:
MUSCULOSKELETAL 1_2:
MUSCULOSKELETAL 2_2:
MUSCULOSKELETAL 3_2:
MUSCULOSKELETAL 4_2:
MUSCULOSKELETAL 5:
MUSCULOSKELETAL 6:
MUSCULOSKELETAL 7:
MUSCULOSKELETAL 8:
MUSCULOSKELETAL 9:
NEUROLOGIC 1_2:
NEUROLOGIC 2_2:
NEUROLOGIC 3_2:
NEUROLOGIC 4_2:
NEUROLOGIC 5_2:
NEUROLOGIC 6_2:
NEUROLOGIC 7:
DIAGNOSIS 1:
DIAGNOSIS 2:
DIAGNOSIS 3:
DIAGNOSIS 4:
1_3:
2_3:
3_3:

MEDICATIONS 1:
MEDICATIONS 2:
MEDICATIONS 3:
MEDICATIONS 4:

MEDICATIONS 5:
MEDICATIONS 6:
MEDICATIONS 7:
MEDICATIONS 8:
MEDICATIONS 9:
MEDICATIONS 10:
MEDICATIONS 11:
MEDICATIONS 12:
MEDICATIONS 13:
MEDICATIONS 14:
MEDICATIONS 15:
FOLLOWUPSREFERRALS 1:
FOLLOWUPSREFERRALS 2:
FOLLOWUPSREFERRALS 3:
FOLLOWUPSREFERRALS 4:
FOLLOWUPSREFERRALS 5:
RATIONALE 1:
RATIONALE 2:
RATIONALE 3:
RATIONALE 4:
RATIONALE 5:
RATIONALE 6:
RATIONALE 7:
RATIONALE 8:
RATIONALE 9:
RATIONALE 10:
RATIONALE 11:
RATIONALE 12:
RATIONALE 13:
1_4:
2_4:
3_4:
4_3:

5_2:

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