NURS 6512 WU Wk 4 Shadow Health Comprehensive SOAP Note Template Worksheet

    1. Assignment 1: You are going to write a SOAP note. Us the template given to you in the Resources section. The skin graphics are also in the Resource section. Choose one graphic to write up for a SOAP note. This is to be written as a SOAP note (NO NARRATIVES). As you write the SOAP note, you must address all sections. If you are not given the information, you will need to make it up. Make sure that you use medical terminology to describe the image. Include 5 differentials and identify which is the most likely diagnosis. I recommend that you use the SOAP exemplar as a guide for this assignment.

    Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.

    In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

    To Prepare

    • Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
    • Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
    • Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
    • Consider which of the conditions is most likely to be the correct diagnosis, and why.
    • Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
    • Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
    • Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.

    The Lab Assignment

    • 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. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
    • 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. 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.
    • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

      • Chapter 9, “Skin, Hair, and Nails”

        This chapter reviews the basic anatomy and physiology of skin, hair, and nails. The chapter also describes guidelines for proper skin, hair, and nails assessments.

      Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.This section explains the procedural knReadings
      • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart,
      R. W. (2019). Seidel’s guide to physical examination: An
      interprofessional approach (9th ed.). St. Louis, MO: Elsevier
      Mosby.
      o Chapter 9, “Skin, Hair, and Nails”
      • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart,
      R. W. (2019). Skin, hair, and nails: Student checklist. In Seidel’s
      guide to physical examination: An interprofessional approach
      (9th ed.). St. Louis, MO: Elsevier Mosby.
      • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart,
      R. W. (2019). Skin, hair, and nails: Key points. In Seidel’s guide
      to physical examination: An interprofessional approach (9th
      ed.). St. Louis, MO: Elsevier Mosby.
      • Clothier, A. (2014). Assessing and managing skin tears in older
      people. Nurse Prescribing, 12(6), 278–282.
      • Colyar, M. R. (2015). Advanced practice nursing procedures.
      Philadelphia, PA: F. A. Davis.
      o Chapter 1, “Punch Biopsyowledge needed prior to performing various dermatological procedures.• Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced
      health assessment and clinical diagnosis in primary care (6th
      ed.). St. Louis, MO: Elsevier Mosby.
      o Chapter 28, “Rashes and Skin Lesions”
      • Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.).
      Philadelphia, PA: F. A. Davis.
      o Chapter 2, “The Comprehensive History and Physical
      Exam” (Previously read in Weeks 1 and 3)
      • VisualDx. (n.d.). Clinical decision support. Retrieved June 11,
      2019, from http://www.skinsight.com/info/for_professionals

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