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 |
