SOAP Note Cardiovascular

About Congestive Heart Failure

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PRIMARY

CARE SOAP NOTE

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  • Student:
  • __________________________

  • Date:
  • ______________

    Professor: ______________________________________________________________

    PATIENT INFORMATION:

    NAME:

    _

    ______

    ________________________________________________________________

  • AGE:
  • ______________

  • SEX:
  • _______________

    CC:__

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    __

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    SUBJECTIVE:

    HPI:_________________________________________________________________________
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    PRIMARY CARE SOAP NOTE

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    ALLERGIES:

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    CURRENTMEDICATIONS_____________________________________________________

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    PMHX:_______________________________________________________________________

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    FAMH:_______________________________________________________________________

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    SOCHX:______________________________________________________________________

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    PRIMARY CARE SOAP NOTE

    REVIEW OF SYSTEMS:

    CONSTITUTIONAL:__________________________________________________________

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    HEENT:

    HEAD:_______________________________________________________________________

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    EYES:________________________________________________________________________

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    EARS:_______________________________________________________________________

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    NOSE:_______________________________________________________________________

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    THROAT:____________________________________________________________________

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    RESPIRATORY:

    ______________________________________________________________________________
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    PRIMARY CARE SOAP NOTE

    ______________________________________________________________________________

    CARDIOVASCULAR__________________________________________________________

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    GASTROINTESTINAL:

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    GENITOURINARY:

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    MUSCULOSKELETAL: _______________________________________________________

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    NEUROLOGIC:_______________________________________________________________

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    PRIMARY CARE SOAP NOTE

    OBJECTIVE:

    CONSTITUTIONAL:

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    SKIN:

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    ________________________________________________________________________
    HEENT:
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    NECK:

    ______________________________________________________________________________
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    ______________________________________________________________________________

    ______________________________________________________________________________

    RESPIRATORY:

    ______________________________________________________________________________
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    PRIMARY CARE SOAP NOTE

    ______________________________________________________________________________
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    CARDIOVASCULAR:

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    GASTROINTESTINAL:

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    PRIMARY CARE SOAP NOTE

    GENITOURINARY:

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    PERIPHERAL VASCULAR:

    ______________________________________________________________________________
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    MUSCULOSKELETAL:

    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________
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    NEUROLOGIC:

    ______________________________________________________________________________
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    ________________________________________________________________

    PRIMARY CARE SOAP NOTE

    ASSESSMENT:

    DIAGNOSIS:

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    DIFFERENTIAL DIAGNOSIS:

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    PRIMARY CARE SOAP NOTE

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    PLAN:

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    Non-

    Pharmacologic treatment:

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    PRIMARY CARE SOAP NOTE

    Pharmacologic treatment:

    MEDICATIONS:

    ______________________________________________________________________________
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    FOLLOW-UPS/REFERRALS:

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    RATIONALE:

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    PRIMARY CARE SOAP NOTE

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      Student:
      Date:
      AGE:
      SEX:

    1. CC
    2. 1:
    3. CC
    4. 2:
    5. CC
    6. 3:
    7. CC
    8. 4:
    9. HPI 1:
    10. HPI 2:
    11. HPI 3:
    12. HPI 4:
    13. HPI
    14. 5:
    15. HPI
    16. 6:
    17. HPI
    18. 7:
    19. HPI
    20. 8:
    21. HPI
    22. 9:
    23. HPI
    24. 10:
    25. HPI
    26. 11:
    27. HPI
    28. 12:
    29. HPI 13:
    30. HPI 14:
    31. HPI 15:
    32. HPI 16:
    33. HPI 17:
    34. HPI 18:
    35. HPI 19:
    36. HPI 20:
    37. HPI 21:
    38. HPI 22:
    39. HPI 23:
    40. HPI 24:
    41. 1:
      2:
      3:
      4:

    42. ALLERGIES 1:
    43. ALLERGIES 2:
    44. ALLERGIES 3:
    45. ALLERGIES 4:
    46. CURRENT
    47. MEDICATIONS 1:
    48. CURRENT
    49. MEDICATIONS 2:
    50. CURRENT
    51. MEDICATIONS 3:
    52. CURRENT
    53. MEDICATIONS 4:
    54. PMHX 1:
    55. PMHX 2:
    56. PMHX 3:
    57. PMHX 4:
    58. FAMH 1:
    59. FAMH 2:
    60. FAMH 3:
    61. FAMH 4:
    62. FAMH 5:
    63. SOCHX 1:
    64. SOCHX 2:
    65. SOCHX 3:
    66. SOCHX 4:
    67. CONSTITUTIONAL 1:
    68. CONSTITUTIONAL 2:
    69. CONSTITUTIONAL 3:
    70. CONSTITUTIONAL 4:
    71. HEAD 1:
    72. HEAD 2:
    73. HEAD 3:
    74. HEAD 4:
    75. EYES 1:
    76. EYES 2:
    77. EYES 3:
    78. EARS 1:
    79. EARS 2:
    80. EARS 3:
    81. NOSE 1:
    82. NOSE 2:
    83. NOSE 3:
    84. THROAT 1:
    85. THROAT 2:
    86. THROAT 3:
    87. THROAT 4:
    88. RESPIRATORY 1:
    89. RESPIRATORY 2:
    90. RESPIRATORY 3:
    91. RESPIRATORY 4:
    92. CARDIOVASCULAR 1:
    93. CARDIOVASCULAR 2:
    94. CARDIOVASCULAR 3:
    95. CARDIOVASCULAR 4:
    96. CARDIOVASCULAR 5:
    97. CARDIOVASCULAR 6:
    98. GASTROINTESTINAL 1:
    99. GASTROINTESTINAL 2:
    100. GASTROINTESTINAL 3:
    101. GASTROINTESTINAL 4:
    102. GASTROINTESTINAL 5:
    103. GASTROINTESTINAL 6:
    104. GENITOURINARY 1:
    105. GENITOURINARY 2:
    106. GENITOURINARY 3:
    107. GENITOURINARY 4:
    108. GENITOURINARY 5:
    109. MUSCULOSKELETAL 1:
    110. MUSCULOSKELETAL 2:
    111. MUSCULOSKELETAL 3:
    112. MUSCULOSKELETAL 4:
    113. NEUROLOGIC 1:
    114. NEUROLOGIC 2:
    115. NEUROLOGIC 3:
    116. NEUROLOGIC 4:
    117. NEUROLOGIC 5:
    118. NEUROLOGIC 6:
    119. CONSTITUTIONAL
    120. 1_2:
    121. CONSTITUTIONAL
    122. 2_2:
    123. CONSTITUTIONAL
    124. 3_2:
    125. CONSTITUTIONAL
    126. 4_2:
    127. SKIN 1:
    128. SKIN 2:
    129. SKIN 3:
    130. SKIN 4:
    131. HEENT 1:
    132. HEENT 2:
    133. HEENT 3:
    134. HEENT 4:
    135. HEENT 5:
    136. HEENT 6:
    137. HEENT 7:
    138. HEENT 8:
    139. HEENT 9:
    140. HEENT 10:
    141. HEENT 11:
    142. HEENT 12:
    143. HEENT 13:
    144. HEENT 14:
    145. NECK 1:
    146. NECK 2:
    147. NECK 3:
    148. NECK 4:
    149. NECK 5:
    150. RESPIRATORY 1_2:
    151. RESPIRATORY 2_2:
    152. RESPIRATORY 3_2:
    153. RESPIRATORY 4_2:
    154. RESPIRATORY 5:
    155. 1_2:
      2_2:
      3_2:
      4_2:
      5:
      6:
      7:
      8:
      9:
      10:
      11:
      12:

    156. CARDIOVASCULAR 1_2:
    157. CARDIOVASCULAR 2_2:
    158. CARDIOVASCULAR 3_2:
    159. CARDIOVASCULAR 4_2:
    160. CARDIOVASCULAR
    161. 5_2:
    162. CARDIOVASCULAR 6_2:
    163. CARDIOVASCULAR 7:
    164. CARDIOVASCULAR 8:
    165. CARDIOVASCULAR 9:
    166. CARDIOVASCULAR 10:
    167. CARDIOVASCULAR 11:
    168. CARDIOVASCULAR 12:
    169. GASTROINTESTINAL 1_2:
    170. GASTROINTESTINAL 2_2:
    171. GASTROINTESTINAL 3_2:
    172. GASTROINTESTINAL 4_2:
    173. GASTROINTESTINAL 5_2:
    174. GASTROINTESTINAL 6_2:
    175. GASTROINTESTINAL 7:
    176. GASTROINTESTINAL 8:
    177. GASTROINTESTINAL 9:
    178. GASTROINTESTINAL 10:
    179. GASTROINTESTINAL 11:
    180. GENITOURINARY 1_2:
    181. GENITOURINARY 2_2:
    182. GENITOURINARY 3_2:
    183. GENITOURINARY 4_2:
    184. GENITOURINARY 5_2:
    185. GENITOURINARY 6:
    186. GENITOURINARY 7:
    187. GENITOURINARY 8:
    188. GENITOURINARY 9:
    189. GENITOURINARY 10:
    190. GENITOURINARY 11:
    191. GENITOURINARY 12:
    192. PERIPHERAL VASCULAR 1:
    193. PERIPHERAL VASCULAR 2:
    194. PERIPHERAL VASCULAR 3:
    195. PERIPHERAL VASCULAR 4:
    196. PERIPHERAL VASCULAR 5:
    197. MUSCULOSKELETAL 1_2:
    198. MUSCULOSKELETAL 2_2:
    199. MUSCULOSKELETAL 3_2:
    200. MUSCULOSKELETAL 4_2:
    201. MUSCULOSKELETAL 5:
    202. MUSCULOSKELETAL 6:
    203. MUSCULOSKELETAL 7:
    204. MUSCULOSKELETAL 8:
    205. MUSCULOSKELETAL 9:
    206. NEUROLOGIC 1_2:
    207. NEUROLOGIC 2_2:
    208. NEUROLOGIC 3_2:
    209. NEUROLOGIC 4_2:
    210. NEUROLOGIC 5_2:
    211. NEUROLOGIC 6_2:
    212. NEUROLOGIC 7:
    213. DIAGNOSIS 1:
    214. DIAGNOSIS 2:
    215. DIAGNOSIS 3:
    216. DIAGNOSIS 4:
    217. 1_3:
    218. 2_3:
    219. 3_3:
    220. MEDICATIONS 1:
      MEDICATIONS 2:
      MEDICATIONS 3:
      MEDICATIONS 4:

    221. MEDICATIONS 5:
    222. MEDICATIONS 6:
    223. MEDICATIONS 7:
    224. MEDICATIONS 8:
    225. MEDICATIONS 9:
    226. MEDICATIONS 10:
    227. MEDICATIONS 11:
    228. MEDICATIONS 12:
    229. MEDICATIONS 13:
    230. MEDICATIONS 14:
    231. MEDICATIONS 15:
    232. FOLLOWUPSREFERRALS 1:
    233. FOLLOWUPSREFERRALS 2:
    234. FOLLOWUPSREFERRALS 3:
    235. FOLLOWUPSREFERRALS 4:
    236. FOLLOWUPSREFERRALS 5:
    237. RATIONALE 1:
    238. RATIONALE 2:
    239. RATIONALE 3:
    240. RATIONALE 4:
    241. RATIONALE 5:
    242. RATIONALE 6:
    243. RATIONALE 7:
    244. RATIONALE 8:
    245. RATIONALE 9:
    246. RATIONALE 10:
    247. RATIONALE 11:
    248. RATIONALE 12:
    249. RATIONALE 13:
    250. 1_4:
    251. 2_4:
    252. 3_4:
    253. 4_3:
    254. 5_2:

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