Week 4
Skin Comprehensive SOAP Note Template
Patient Initials: _______Age: _______Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:
Immunization History:
Significant Family History:
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails:
OBJECTIVE DATA:
Physical Exam:
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:.
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic results:
ASSESSMENT:
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
7
Comprehensive Soap Note
References
American Academy of Dermatology. (n.d.). Petechiae, purpura, and vasculitis.
Retrieved from file:///C:/Users/User/Downloads/Petechiae--Purpura-and-Vasculitis.pdf
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015).
Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Gupta, J., Kandhari, R., Ramesh, V., & Singh, A. (2013). Glomeruloid
hemangioma in normal individuals. Indian Journal of Dermatology, 58(2), 160.
doi:10.4103/0019-5154.108088
Kim, J., Park, H., & Ahn, S. K. (2009). Cherry Angiomas on the Scalp. Case
Reports In Dermatology, 1(1), 82-86. Retrieved from Walden Library database
Sanz, V., Martorell, A., Alegria-Landa, V., Diaz, F. J., Torrelo, A., Alfaro-Rubio,
A., & Kutzner, H. (2017). Cherry hemanginomas and lipomas with peculiar distribution.
Journal of the American Academy of Dermatology. 76(6). DOI:
https://doi.org/10.1016/j.jaad.2017.04.280
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