BJFill in form veterans outpatient

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