Heart Failure in Older Adults
Patient 65 years or older- MUST FOLLOW RUBRIC COMPLETELY
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
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Instructions:
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up
Click here to access and download the SOAP Note TemplateDownload Click here to access and download the SOAP Note Template
Submission Instructions:
- Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
Heart Failure in Older Adults
S – Subjective
Chief Complaint (CC):
“I’ve been feeling very tired lately, and I get short of breath when walking up stairs.”
History of Present Illness (HPI):
Mary Johnson is a 68-year-old female presenting with increasing fatigue and exertional dyspnea over the past 2 months. She reports occasional mild ankle swelling and has had difficulty sleeping due to needing to prop herself up with pillows. No chest pain, palpitations, or recent weight gain. No fever, cough, or upper respiratory symptoms. Denies dizziness or syncope.
Past Medical History (PMH):
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Hypertension
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Type 2 Diabetes Mellitus
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Hyperlipidemia
Surgical History:
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Appendectomy at age 22
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Cataract surgery (left eye) at age 65
Family History:
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Mother: Deceased, myocardial infarction at 72
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Father: Deceased, stroke at 75
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Sibling: Brother alive, diabetes and hypertension
