Selecting cronic heart failure discuses filling the attached form.

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Discussion Topic: Selecting Cronic heart failure, discuses filling the attached form.

Requirements

 The discussion must address the topic

 Rationale must be provided

 Use at least 600 words (no included 1 st page or references in the 600 words)

 May use examples from your nursing practice

 Formatted and cited in current APA 7

 Use 3 academic sources, not older than 5 years. Not Websites are allowed.

 Plagiarism is NOT permitted

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications:

1.

PMH:

Immunizations:

Preventive Care:

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:


Subjective Data:

Chief Complaint:

Symptom analysis/HPI:

The patient is …


Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:


Objective Data:

VITAL SIGNS:

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:


ASSESSMENT:


(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)


Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 7th Edition.

Differential diagnosis (minimum 4)


PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

1. –

1. –

Pharmacological treatment:

Non-Pharmacologic treatment:

Education (provide the most relevant ones tailored to your patient)

Follow-ups/Referrals

References (in APA Style)


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