SOAP Note Cardiovascular About Congestive Heart Failure PRIMARY CARE SOAP NOTE Student: __________________________ Date: ______________ Professor: __

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About Congestive Heart Failure

PRIMARY CARE SOAP NOTE

Student: __________________________ Date: ______________

Professor: ______________________________________________________________

PATIENT INFORMATION:

NAME:

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AGE: ______________SEX: _______________

CC:__________________________________________________________________________
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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

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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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  1. Student:
  2. Date:
  3. AGE:
  4. SEX:
  5. CC 1:
  6. CC 2:
  7. CC 3:
  8. CC 4:
  9. HPI 1:
  10. HPI 2:
  11. HPI 3:
  12. HPI 4:
  13. HPI 5:
  14. HPI 6:
  15. HPI 7:
  16. HPI 8:
  17. HPI 9:
  18. HPI 10:
  19. HPI 11:
  20. HPI 12:
  21. HPI 13:
  22. HPI 14:
  23. HPI 15:
  24. HPI 16:
  25. HPI 17:
  26. HPI 18:
  27. HPI 19:
  28. HPI 20:
  29. HPI 21:
  30. HPI 22:
  31. HPI 23:
  32. HPI 24:
  33. 1:
  34. 2:
  35. 3:
  36. 4:
  37. ALLERGIES 1:
  38. ALLERGIES 2:
  39. ALLERGIES 3:
  40. ALLERGIES 4:
  41. CURRENTMEDICATIONS 1:
  42. CURRENTMEDICATIONS 2:
  43. CURRENTMEDICATIONS 3:
  44. CURRENTMEDICATIONS 4:
  45. PMHX 1:
  46. PMHX 2:
  47. PMHX 3:
  48. PMHX 4:
  49. FAMH 1:
  50. FAMH 2:
  51. FAMH 3:
  52. FAMH 4:
  53. FAMH 5:
  54. SOCHX 1:
  55. SOCHX 2:
  56. SOCHX 3:
  57. SOCHX 4:
  58. CONSTITUTIONAL 1:
  59. CONSTITUTIONAL 2:
  60. CONSTITUTIONAL 3:
  61. CONSTITUTIONAL 4:
  62. HEAD 1:
  63. HEAD 2:
  64. HEAD 3:
  65. HEAD 4:
  66. EYES 1:
  67. EYES 2:
  68. EYES 3:
  69. EARS 1:
  70. EARS 2:
  71. EARS 3:
  72. NOSE 1:
  73. NOSE 2:
  74. NOSE 3:
  75. THROAT 1:
  76. THROAT 2:
  77. THROAT 3:
  78. THROAT 4:
  79. RESPIRATORY 1:
  80. RESPIRATORY 2:
  81. RESPIRATORY 3:
  82. RESPIRATORY 4:
  83. CARDIOVASCULAR 1:
  84. CARDIOVASCULAR 2:
  85. CARDIOVASCULAR 3:
  86. CARDIOVASCULAR 4:
  87. CARDIOVASCULAR 5:
  88. CARDIOVASCULAR 6:
  89. GASTROINTESTINAL 1:
  90. GASTROINTESTINAL 2:
  91. GASTROINTESTINAL 3:
  92. GASTROINTESTINAL 4:
  93. GASTROINTESTINAL 5:
  94. GASTROINTESTINAL 6:
  95. GENITOURINARY 1:
  96. GENITOURINARY 2:
  97. GENITOURINARY 3:
  98. GENITOURINARY 4:
  99. GENITOURINARY 5:
  100. MUSCULOSKELETAL 1:
  101. MUSCULOSKELETAL 2:
  102. MUSCULOSKELETAL 3:
  103. MUSCULOSKELETAL 4:
  104. NEUROLOGIC 1:
  105. NEUROLOGIC 2:
  106. NEUROLOGIC 3:
  107. NEUROLOGIC 4:
  108. NEUROLOGIC 5:
  109. NEUROLOGIC 6:
  110. CONSTITUTIONAL 1_2:
  111. CONSTITUTIONAL 2_2:
  112. CONSTITUTIONAL 3_2:
  113. CONSTITUTIONAL 4_2:
  114. SKIN 1:

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