SkinComprehensiveSOAPNoteTemplate1.docx

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.

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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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