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BJ fill in form enhance follow up veterans outpatient **files (1)** – ## 1SOAPNoteTemplate-Final1_124176454116.pdf **## 1SOAPNoteTemplate-Final1_124176454116.pdf** SOAP Note NU : Herzing University Name: Typhon Encounter #: Comprehensive: Focused: S: SUBJECTIVE DATA CC: Breathlessness on exertion….
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BJ fill in form enhance follow up veterans outpatient
**files (1)**
– ## 1SOAPNoteTemplate-Final1_124176454116.pdf
**## 1SOAPNoteTemplate-Final1_124176454116.pdf**
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
S: SUBJECTIVE DATA
CC: Breathlessness on exertion.
HPI: History: dyspnea (progressive shortness of breath) more than three months.
Location: Respiratory/cardiac system.
Time: Slow development, which becomes aggravated by exertion.
Features: Exertional dyspnea, fatigue and swelling of the ankle.
Associated Factors: History of hypertension and hyperlipidemia.
Relieving Factors: Partially relieved by rest.
Treatment: Lisinopril, Furosemide and Atorvastatin.
Summary: A 68-year-old male patient with a Caucasian racial background reports
increasing cases of exertional dyspnea, fatigue and peripheral edema within three
months.
PMH: Hypertension, hyperlipidemia.
ALLERGIES NKDA
MEDICATIONS Lisinopril 20 mg daily; Furosemide 20mg daily; Atorvastatin 20 mg nightly
SH Denies smoking, infrequent alcohol consumption.
FH Cardiovascular disease history
HEALTH
PROMOTION &
MAINTENANCE
Patient denies severe physical exercise, walks daily. Balanced diet reported.
Vaccinations are current with influenza vaccine. Examined eyes previously last
year.
ROS
(put N/A in sections
not completed day of
exam)
Constitutional Feeling fatigued.
Head N/A
Eyes N/A
Ears, Nose, Mouth, Throat N/A
Neck N/A
Cardiovascular/Peripheral
Vascular
Denies edema.
Respiratory Denies dyspnea.
Breast N/A
Gastrointestinal N/A
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
Genitourinary N/A
Musculoskeletal N/A
Integumentary N/A
Neurological N/A
Psychiatric (screening tools: Ex:
PHQ-9, MMSE, GAD-7)
N/A.
Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic NKDA.
Other N/A
O: OBJECTIVE DATA
VITALS: HR:Normal RR: Low BP: elevated Temp:
SpO2% Ht: Wt: BMI
Age:68 LMP: PAIN:0/10
PHYSICAL
EXAM
(Pertinent data
related to
presenting
problem or
visit type. Put
N/A in sections
not completed
day of exam)
General Appearance Mild exercise intolerance.
Head N/A
Eyes N/A
ENT, Mouth N/A.
Neck N/A
Cardiovascular/Peripheral Vascular Possible S3, peripheral edema.
Respiratory Crackles in the basal lungs.
Breast
Gastrointestinal N/A
Genitourinary Male
• External Exam N/A
• Internal Exam N/A
Genitourinary Female
• External Exam N/A
• Internal Exam N/A
Musculoskeletal Normal
Integumentary N/A
Neurological Awake and alert.
Psychiatric N/A
Endocrine N/A
Hematologic/Lymphatic N/A
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
Allergic/Immunologic N/A
Other N/A
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
PRIORITIZE
DIAGNOSIS
1. Congestive Heart Failure ICD-10 I50.9
2.
3.
VISIT CODES CPT BILLING CODES CPT-9: 99214
DIAGNOSTICS POC TESTING CPT-10: 99214
TESTS REVIEWED
P: PLAN
ACTIONS 1. Diagnosis: Congestive Heart Failure
Diagnosis
BNP, echocardiogram, chest X-ray.
Therapeutic:
Lisinopril and Furosemide should be continued; diuretics should be changed
depending on necessity.
Education:
Low sodium diet, checking weight daily, taking medication.
Consultation/Collaboration:
Cardiology consultation.
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
2. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
3. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
PREVENTITIVE
(Used for
comprehensive exams)
Enter Guidance, Health Promotion, and/or Disease Prevention for
patient, family, and/or caregiver.
FOLLOW UP 2–4 weeks
**## 1SOAPNoteTemplate-Final1_124176454116.pdf**
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
S: SUBJECTIVE DATA
CC: Breathlessness on exertion.
HPI: History: dyspnea (progressive shortness of breath) more than three months.
Location: Respiratory/cardiac system.
Time: Slow development, which becomes aggravated by exertion.
Features: Exertional dyspnea, fatigue and swelling of the ankle.
Associated Factors: History of hypertension and hyperlipidemia.
Relieving Factors: Partially relieved by rest.
Treatment: Lisinopril, Furosemide and Atorvastatin.
Summary: A 68-year-old male patient with a Caucasian racial background reports
increasing cases of exertional dyspnea, fatigue and peripheral edema within three
months.
PMH: Hypertension, hyperlipidemia.
ALLERGIES NKDA
MEDICATIONS Lisinopril 20 mg daily; Furosemide 20mg daily; Atorvastatin 20 mg nightly
SH Denies smoking, infrequent alcohol consumption.
FH Cardiovascular disease history
HEALTH
PROMOTION &
MAINTENANCE
Patient denies severe physical exercise, walks daily. Balanced diet reported.
Vaccinations are current with influenza vaccine. Examined eyes previously last
year.
ROS
(put N/A in sections
not completed day of
exam)
Constitutional Feeling fatigued.
Head N/A
Eyes N/A
Ears, Nose, Mouth, Throat N/A
Neck N/A
Cardiovascular/Peripheral
Vascular
Denies edema.
Respiratory Denies dyspnea.
Breast N/A
Gastrointestinal N/A
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
Genitourinary N/A
Musculoskeletal N/A
Integumentary N/A
Neurological N/A
Psychiatric (screening tools: Ex:
PHQ-9, MMSE, GAD-7)
N/A.
Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic NKDA.
Other N/A
O: OBJECTIVE DATA
VITALS: HR:Normal RR: Low BP: elevated Temp:
SpO2% Ht: Wt: BMI
Age:68 LMP: PAIN:0/10
PHYSICAL
EXAM
(Pertinent data
related to
presenting
problem or
visit type. Put
N/A in sections
not completed
day of exam)
General Appearance Mild exercise intolerance.
Head N/A
Eyes N/A
ENT, Mouth N/A.
Neck N/A
Cardiovascular/Peripheral Vascular Possible S3, peripheral edema.
Respiratory Crackles in the basal lungs.
Breast
Gastrointestinal N/A
Genitourinary Male
• External Exam N/A
• Internal Exam N/A
Genitourinary Female
• External Exam N/A
• Internal Exam N/A
Musculoskeletal Normal
Integumentary N/A
Neurological Awake and alert.
Psychiatric N/A
Endocrine N/A
Hematologic/Lymphatic N/A
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
Allergic/Immunologic N/A
Other N/A
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
PRIORITIZE
DIAGNOSIS
1. Congestive Heart Failure ICD-10 I50.9
2.
3.
VISIT CODES CPT BILLING CODES CPT-9: 99214
DIAGNOSTICS POC TESTING CPT-10: 99214
TESTS REVIEWED
P: PLAN
ACTIONS 1. Diagnosis: Congestive Heart Failure
Diagnosis
BNP, echocardiogram, chest X-ray.
Therapeutic:
Lisinopril and Furosemide should be continued; diuretics should be changed
depending on necessity.
Education:
Low sodium diet, checking weight daily, taking medication.
Consultation/Collaboration:
Cardiology consultation.
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
2. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
3. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
PREVENTITIVE
(Used for
comprehensive exams)
Enter Guidance, Health Promotion, and/or Disease Prevention for
patient, family, and/or caregiver.
FOLLOW UP 2–4 weeks
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