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.
• Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
• Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose.
• Determine which is most likely to be the correct diagnosis and explain your reasoning using at least 3 different references from current evidence based literature.Comprehensive SOAP Template
This template is for a full history and physical. For this course include only areas that are related to the case.
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
L =location
O= onset
C= character
A= associated signs and symptoms
T= timing
E= exacerbating/relieving factors
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
What pt may tell you.
OBJECTIVE DATA: Do not use “WNL” or “normal.” You must describe what you see.
Physical Exam:Skin:
ASSESSMENT: List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. 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.
Sample Solution