Properly identifying the cause and type of a patients 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 s 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.
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
SOAP NOTE DOCUMENTATION
DURING WEEK 4, You will start writing SOAP notes!
You will be MAKING UP the necessary information needed to do your Soap notes for Assignment 1. You will do the same for Week 5, and 9.
For Week 3 Assignment 1, Please DO NOT include a copy of the picture in the SOAP note. Put the PIC# in the CC
FOLLOW the Template for each SOAP note.
To say N/A or Non contributory is NOT acceptable.
PLEASE, Remove the INSTRUCTIONS/DIRECTIONS on your templates before submitting your FINAL copy.
The directions are for YOU not for grading purposes.
Please REMOVE the INSTRUCTIONS prior to Submitting your Assignment.
For Episodic/Focus Soap Notes, you do not have to Review all the systems, only the ones that are related to the Chief Complaint (CC).
ALWAYS Review and Examine the Respiratory and Cardiovascular systems no matter the complaint.
**You will need to MAKE UP the missing information in the note (Information you will have to MAKE UP, INCLUDES BUT NOT LIMITED TO: Allergies, Medications, Past Medical History, Surgical History, Family History, parts of the Review of Systems (ROS) and Physical Exam).
You NEED TO KNOW what information to include in a SOAP note.
S- Subjective – What the patient tells you. Please be sure your ROS exemplify this.
O – Objective – What you find when you examine your patient, is what you observe, feel, hear and find when doing your exam.
A – Assessment – This is where your diagnoses and differential diagnoses are documented.
In this class you are functioning as an Nurse Practitioner, not as a Registered Nurse (RN).
Please do not put a Summary of findings in the Assessment area, this is RN documentation for Assessment.
P- Planning – Not required for this class. No points are given if you provide this information.
In the ASSESSMENT/PLAN, you will document your differential diagnoses as per the assignment.
List different possible conditions for the patient’s differential diagnosis.
YOU WILL MAKE UP INFORMATION IN ORDER TO COMPLETE THE SUBJECTIVE AND OBJECTIVE INFORMATION for SOAP notes. This DOES NOT apply to Shadow Health SOAP notes!
Each WEEK you will use the SOAP NOTE Template that is designated for this assignment. It is near the bottom of your Resource LIST!
It will be the Comprehensive SOAP Template or Episodic/Focused SOAP Note Template depending on the WEEK.
Examples of SOAP notes are provided under your Resources for each Week.
TO PREPARE
Review the Skin Conditions document provided in this weeks 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 weeks Learning Resources to guide you as you prepare your SOAP note.
Download the SOAP Template found in this weeks 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 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 weeks Learning Resources.
Week 4
Skin Comprehensive SOAP Note TemplatePatient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA: This is what the patient tells you!Chief Complaint (CC): This is the reason the patient comes to see you. Should be a Statement. (Make it up). Be sure to include the Pic # in the CC). (You are making up this information).History of Present Illness (HPI): The tells the story as to why the patient came. Start off with age and sex of patient i.e, 24 y/o Caucasian female presented to clinic with complaint of
Include Location, Onset, Character, Associated S/S, Timing, Exacerbating/Relieving Factors and Severity. (LOCATES)
(You are making up this information).Medications: You will make up the medications, LIST them each on a separate line. (You are making up this information).Allergies: List each allergy on a separation with the reaction. (You are making up this information).Past Medical History (PMH): Include all past and present medical history and medical problems. (You are making up this information).Past Surgical History (PSH): Include all Surgical history, past and present. (You are making up this information). Sexual/Reproductive History: This includes Partners, Practices, Past History of STIs Protection, (WOMEN ONLY) Pregnancies, Onset of Menses, LMP, and Pregnancy Prevention and Reproductive Life Plan.
(You are making up this information).Personal/Social History: Include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
(You are making up this information).Health Maintenance: Include tings like, Breast Cancer Screening, Colorectal Cancer Screening, Cervical Cancer Screening, Diabetes Eye Exam, Advanced Care Plan.
(You are making up this information).Immunization History: Include immunization status (note date of last tetanus for all adults). For children, include all immunizations.
(You are making up this information).Significant Family History: Review of Systems: This is what the patient tells you!
(You are making up this information). It is what the patient denies, admits to, endorses, reports, etc.
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails: This is the system where the CC is, be sure to think about what you would say if you had the assigned condition. What would you c/ and what you would say. Document it here.
(You are making up this information).
OBJECTIVE DATA: Physical Exam: This is your findings when you examine your patient. Cannot say, N/A, WNL, Not examined. (You are making up this information).
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin: This is the system where the CC is, be sure to think about what you see when you examine your patient. Document what you see on the picture. Use clinical terminologies to explain the physical characteristics featured in the graphic.Diagnostic results: You are to make these up diagnosis according to the readings. What diagnostics are relevant to your assigned picture. You are coming up with these.ASSESSMENT:
Formulate a different diagnosis of three to five possible considerations for the skin graphic. Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
NURS_6512_Week_4_Assignment_1_Rubric
NURS_6512_Week_4_Assignment_1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeUsing the SOAP (Subjective, Objective, Assessment, and Plan) note format: · Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). · Use clinical terminologies to explain the physical characteristics featured in the graphic.
35 to >29.0 pts
Excellent
The response clearly, accurately, and thoroughly follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response clearly and thoroughly explains all physical characteristics featured in the graphic using accurate terminologies.
29 to >23.0 pts
Good
The response accurately follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response explains most physical characteristics featured in the graphic using accurate terminologies.
23 to >17.0 pts
Fair
The response follows the SOAP format, with vagueness and some inaccuracy in documenting one skin condition graphic, and accurately identifies the graphic by number in the Chief Complaint. The response explains some physical characteristics featured in the graphic using mostly accurate terminologies.
17 to >0 pts
Poor
The response inaccurately follows the SOAP format or is missing documentation for one skin condition graphic and is missing or inaccurately identifies the graphic by number in the Chief Complaint. The response explains some or few physical characteristics featured in the graphic using terminologies with multiple inaccuracies.
35 pts
This criterion is linked to a Learning Outcome· Formulate a different diagnosis of three to five possible considerations for the skin graphic. · Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.
50 to >44.0 pts
Excellent
The response clearly, thoroughly, and accurately formulates a different diagnosis of five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.
44 to >38.0 pts
Good
The response accurately formulates a different diagnosis of three to five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained accurately using at least three different references from current evidence-based literature.
38 to >32.0 pts
Fair
The response vaguely or with some inaccuracy formulates a different diagnosis of three possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained vaguely and with some inaccuracy using three different references from current evidence-based literature.
32 to >0 pts
Poor
The response formulates inaccurately, incompletely, or is missing a different diagnosis of possible considerations for the skin graphic, with two or fewer possible considerations provided. The response vaguely, inaccurately, or incompletely determines the most likely correct diagnosis with reasoning that is missing or explained using two or fewer different references from current evidence-based literature.
50 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 pts
Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 to >3.0 pts
Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
3 to >2.0 pts
Fair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
2 to >0 pts
Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. 5 pts This criterion is linked to a Learning OutcomeWritten Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.
2 to >0 pts
Poor
Contains many (= 5) grammar, spelling, and punctuation errors that interfere with the readers understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 pts
Excellent
Uses correct APA format with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) APA format errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) APA format errors.
2 to >0 pts
Poor
Contains many (= 5) APA format errors.
5 pts
Total Points: 100
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