Herzing University SOAP Note Example: Veterans Outpatient Congestive Heart Failure Case for NP Students

Nurse practitioner students completing a Veterans outpatient SOAP note for a 68-year-old male presenting with exertional dyspnea, peripheral edema, and a history of hypertension will find this Herzing University Typhon encounter walkthrough covers every required section from subjective data through the follow-up plan, with ICD-10 coding and cardiology referral guidance included.

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SOAP Note — Herzing University (Typhon Encounter)

Setting: Veterans Outpatient Clinic
Encounter Type: Comprehensive / Focused
Course: NU (Nurse Practitioner Clinical)

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S: SUBJECTIVE DATA

Chief Complaint (CC)

Breathlessness on exertion.

History of Present Illness (HPI)

• History: Dyspnea (progressive shortness of breath) for 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 Caucasian male reports increasing episodes of exertional dyspnea, fatigue, and peripheral edema over the past three months. These symptoms align with a clinical picture that warrants prompt cardiac workup, particularly given his longstanding history of hypertension and hyperlipidemia, both of which are well-established risk factors for the development of heart failure in older adults.

Past Medical History (PMH)

Hypertension, hyperlipidemia.

Allergies

NKDA (No Known Drug Allergies)

Medications

• Lisinopril 20 mg daily
• Furosemide 20 mg daily
• Atorvastatin 20 mg nightly

It is worth noting that the current Furosemide dose of 20 mg daily may be on the lower end for managing volume overload in a patient presenting with basal crackles and peripheral edema; dose titration should be evaluated after diagnostic results are reviewed.

Social History (SH)

Denies smoking; reports infrequent alcohol consumption.

Family History (FH)

Cardiovascular disease history.

Health Promotion and Maintenance

• Patient denies severe physical exercise; walks daily.
• Balanced diet reported.
• Vaccinations are current, including influenza vaccine.
• Eyes examined the previous year.

Review of Systems (ROS)

(N/A entered in sections not completed on the 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. (Note: This subjective denial contrasts with objective peripheral edema findings and should be explored further in patient education and counseling.)
• Respiratory: Denies dyspnea. (Note: Patient subjectively denies dyspnea here, yet the CC describes breathlessness on exertion; this discrepancy may reflect a minimization of symptoms, which is not uncommon in older male veterans and should be addressed during counseling.)
• Breast: N/A
• Gastrointestinal: N/A
• Genitourinary: N/A
• Musculoskeletal: N/A
• Integumentary: N/A
• Neurological: N/A
• Psychiatric (PHQ-9, MMSE, GAD-7): N/A
• Endocrine: N/A
• Hematologic/Lymphatic: N/A
• Allergic/Immunologic: NKDA
• Other: N/A

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O: OBJECTIVE DATA

Vitals

• HR: Normal
• RR: Low
• BP: Elevated
• Temp: [Enter value]
• SpO2%: [Enter value]
• Ht: [Enter value]
• Wt: [Enter value]
• BMI: [Enter value]
• Age: 68
• LMP: N/A (male patient)
• Pain: 0/10

Elevated blood pressure in this patient may reflect inadequate blood pressure control on the current Lisinopril dose or suboptimal medication adherence; either scenario should be clarified during the visit and documented accordingly before any medication adjustments are made.

Physical Exam

(Pertinent data related to the presenting problem. N/A entered in sections not completed on the 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 gallop; peripheral edema present. The presence of an S3 gallop in a 68-year-old male with progressive exertional dyspnea and peripheral edema is a significant physical finding that strongly suggests elevated ventricular filling pressures and is associated with decompensated heart failure until proven otherwise.
• Respiratory: Crackles in the basal lungs.
• Breast: N/A
• Gastrointestinal: N/A
• Genitourinary (Male): External Exam N/A; Internal Exam N/A
• Genitourinary (Female): N/A
• Musculoskeletal: Normal
• Integumentary: N/A
• Neurological: Awake and alert.
• Psychiatric: N/A
• Endocrine: N/A
• Hematologic/Lymphatic: N/A
• Allergic/Immunologic: N/A
• Other: N/A

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A: ASSESSMENT AND DIAGNOSIS

Prioritized Diagnosis List

1. Congestive Heart Failure
   ICD-10 Code: I50.9 (Heart failure, unspecified)
   Rationale: The combination of a three-month history of progressive exertional dyspnea, bilateral basal crackles, peripheral edema, a possible S3 gallop on auscultation, elevated blood pressure, and a background of hypertension and hyperlipidemia collectively support CHF as the primary working diagnosis pending confirmatory diagnostics. Clinicians should consider further specifying the type of heart failure (HFrEF vs. HFpEF) once echocardiographic data are available, as management strategies differ meaningfully between the two presentations.
2. [Secondary Diagnosis — Pending Workup]
3. [Tertiary Diagnosis — Pending Workup]

Visit Codes / CPT Billing Codes

• CPT-9: 99214
• CPT-10: 99214

Diagnostics / POC Testing

[Tests Reviewed — Enter results as available]

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P: PLAN

Diagnosis 1: Congestive Heart Failure (ICD-10: I50.9)

Diagnostics Ordered

• BNP (B-type natriuretic peptide) level
• Echocardiogram
• Chest X-ray

A BNP level above 100 pg/mL in a symptomatic patient is generally considered supportive of a heart failure diagnosis, and values above 400 pg/mL suggest a high probability of decompensated CHF; results should be interpreted alongside the echocardiogram findings for the most clinically accurate picture (Yancy et al., 2022).

Therapeutic

• Continue Lisinopril and Furosemide.
• Reassess and adjust diuretic dosing based on clinical response and diagnostic findings.
• Consider adding a beta-blocker such as carvedilol or metoprolol succinate if the ejection fraction is reduced on echo, as per current ACC/AHA heart failure guidelines.

Patient Education

• Low-sodium diet (target less than 2 g/day).
• Daily weight monitoring with instructions to call the clinic if weight increases by more than 2–3 lbs in 24 hours or 5 lbs in one week.
• Medication adherence counseling.
• Activity pacing strategies to reduce exertional dyspnea while maintaining cardiovascular health.

Consultation/Collaboration

• Cardiology consultation ordered.
• Consider referral to a heart failure disease management program if available through the Veterans Affairs system, as structured multidisciplinary programs have been shown to reduce 30-day readmission rates in heart failure patients by up to 20% (Feltner et al., 2019).

Diagnosis 2

• Diagnostics Order: [Pending]
• Therapeutic: [Pending]
• Education: [Pending]
• Consultation/Collaboration: [Pending]

Diagnosis 3

• Diagnostics Order: [Pending]
• Therapeutic: [Pending]
• Education: [Pending]
• Consultation/Collaboration: [Pending]

Preventive / Health Promotion (Comprehensive Exam Guidance)

• Reinforce influenza vaccination; ensure pneumococcal vaccination status is reviewed given the patient’s age and cardiac diagnosis.
• Encourage continuation of daily walking while advising the patient to stop and rest if breathlessness worsens.
• Screen for depression using the PHQ-9, as depression affects approximately 20–40% of patients with heart failure and is associated with worse clinical outcomes if left unaddressed.
• Counsel patient and family/caregiver on early warning signs of decompensation and when to seek emergency care.

Follow-Up

2 to 4 weeks, or sooner if symptoms worsen before the scheduled appointment.

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Sample Answer / Example SOAP Note Response for NP Students

Comprehensive SOAP Note Walkthrough: CHF in a 68-Year-Old Male Veteran

When completing a Veterans outpatient SOAP note for a patient presenting with progressive exertional dyspnea, the subjective section must capture not only the chief complaint but also the full context of symptom progression, aggravating and relieving factors, and current medication use. In this case, the 68-year-old male veteran’s three-month history of worsening breathlessness on exertion, ankle swelling, and fatigue, set against a background of hypertension and hyperlipidemia, provides a clinically coherent picture that points toward a cardiac etiology. The objective section strengthens this working diagnosis considerably, as bilateral basal crackles suggest pulmonary congestion, peripheral edema indicates fluid retention, and the possible S3 gallop on cardiac auscultation is a classic sign of volume overload in the failing ventricle. According to the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Heidenreich et al., 2022), the combination of these physical findings alongside elevated BNP and echocardiographic evidence of reduced or preserved ejection fraction confirms the CHF diagnosis and guides the specific pharmacological strategy selected. The plan appropriately continues ACE inhibitor therapy with Lisinopril and loop diuretic therapy with Furosemide, orders confirmatory diagnostics including BNP, chest X-ray, and echocardiogram, and initiates a cardiology referral, all of which align with current evidence-based heart failure management protocols for outpatient veteran populations.

Heart failure affects approximately 6.7 million adults in the United States, and Veterans are disproportionately represented in this population due to the high prevalence of hypertension, obesity, and service-related cardiovascular risk factors within this group (Centers for Disease Control and Prevention, 2023). Nurse practitioners managing heart failure in Veterans outpatient settings must be proficient in Typhon SOAP note documentation, as accurate and structured clinical records directly affect billing accuracy, continuity of care, and quality metrics reported to the VA healthcare system. The ACC/AHA guidelines emphasize that guideline-directed medical therapy (GDMT), which includes ACE inhibitors or ARNIs, beta-blockers, and mineralocorticoid receptor antagonists where indicated, significantly reduces mortality and hospitalization in patients with heart failure with reduced ejection fraction; failure to initiate or titrate these agents appropriately represents a measurable quality gap in outpatient care. Patient education on daily weight monitoring, sodium restriction, and early recognition of decompensation signs has been shown to reduce 30-day readmission rates in heart failure populations when delivered consistently at each outpatient encounter (Feltner et al., 2019). NP students completing SOAP notes for similar cases on Typhon should ensure that each section, from the HPI through the plan, reflects clinical reasoning that is specific to the patient’s presentation rather than generic template language, as instructors evaluate not just documentation completeness but the depth of diagnostic thinking evident throughout the note.

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References

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., . . . Yancy, C. W. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure. Journal of the American College of Cardiology, 79(17), e263–e421. https://doi.org/10.1016/j.jacc.2022.02.010

Feltner, C., Jones, C. D., Cene, C. W., Zheng, Z. J., Sueta, C. A., Coker-Schwimmer, E. J., Arvanitis, M., Lohr, K. N., Middleton, J. C., & Jonas, D. E. (2019). Transitional care interventions to prevent readmissions for persons with heart failure. Annals of Internal Medicine, 160(11), 774–784. https://doi.org/10.7326/M14-0083

Centers for Disease Control and Prevention. (2023). Heart failure facts and statistics. U.S. Department of Health and Human Services. https://www.cdc.gov/heartdisease/heart_failure.htm

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., Drazner, M. H., Filippatos, G. S., Fonarow, G. C., Givertz, M. M., Hollenberg, S. M., Lindenfeld, J., Masoudi, F. A., McBane, R. D., Peterson, P. N., Shah, S. J., & Stevenson, L. W. (2022). ACC/AHA/HFSA focused update of the 2013 guideline for the management of heart failure. Journal of the American College of Cardiology, 70(6), 776–803. https://doi.org/10.1016/j.jacc.2017.04.025

Dunlay, S. M., Roger, V. L., & Redfield, M. M. (2017). Epidemiology of heart failure with preserved ejection fraction. Nature Reviews Cardiology, 14(10), 591–602. https://doi.org/10.1038/nrcardio.2017.65

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Research study bay topics

1. Veterans Outpatient SOAP Note Example for CHF: Herzing University Typhon NP Clinical Documentation Guide
2. Herzing University SOAP Note Congestive Heart Failure Veterans Outpatient Typhon NP Clinical Example APA
3. How to Complete a Typhon SOAP Note for Congestive Heart Failure in Veterans Outpatient NP Clinicals
4. When exertional dyspnea, peripheral edema, and a positive S3 gallop present together in a veteran patient

• Complete a 500-to-700-word Veterans outpatient SOAP note for a 68-year-old male presenting with congestive heart failure, covering subjective HPI, objective physical exam findings, ICD-10 diagnosis coding, and a cardiology-informed plan section using Herzing University’s Typhon encounter format.
• Submit a 2-to-3-page Typhon SOAP note for a Veterans outpatient NP clinical encounter documenting congestive heart failure with exertional dyspnea, peripheral edema, basal crackles, elevated BP, and a full plan including BNP, echocardiogram, and cardiology referral per Herzing University NP program requirements.
•  Document a comprehensive Veterans outpatient SOAP note for congestive heart failure in a 68-year-old veteran using the Herzing University Typhon encounter template, with ICD-10 code I50.9, CPT 99214, and a cardiology referral plan.

 

Assignment: Week [Following Clinical Module] — SOAP Note for Respiratory or Endocrine Presentation in Veterans Outpatient Setting

Course: NU Clinical Practicum — Herzing University Nurse Practitioner Program (Typhon Documentation)

In the next clinical documentation assignment, students will most likely be required to complete a Typhon SOAP note for a Veterans outpatient encounter involving a respiratory condition such as COPD exacerbation or an endocrine presentation such as poorly controlled Type 2 diabetes mellitus, both of which are highly prevalent in the veteran population and commonly assessed in NP practicum documentation modules. Students should document a full subjective section including a detailed HPI, complete ROS, relevant PMH, medications, allergies, and social history, followed by an objective section that includes specific spirometry or HbA1c values, physical exam findings, and accurate vital signs with no placeholder entries. The assessment section must include at least two prioritized differential diagnoses with correct ICD-10 codes, and the plan section must reflect evidence-based practice aligned with current GOLD guidelines for COPD or ADA Standards of Medical Care for diabetes management. All documentation must be completed in the Typhon encounter system, and the note must demonstrate clinical reasoning appropriate to a mid-level provider rather than a student-level summary. As with prior SOAP note assignments, APA 7th edition formatting applies to all in-text citations and reference entries included in the written reflection or clinical reasoning narrative that accompanies the Typhon note.