SOAP Note Assignment: Skin Condition Differential Diagnosis

1 Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style.  Remember that not all comprehensive SOAP data are included in every patient case.

2 Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose.

3.Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:

1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.

This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.

Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.

Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.

Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?