NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning

Week 4 Lab Assignment: SOAP Note – Assessment of Skin Conditions

Course and Assessment Overview

Course: NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning (Graduate/APRN level)

Assessment type: Individual written SOAP note lab assignment

Suggested timing: Week 4 (Skin, Hair, and Nails; early–mid term), aligned with other system-focused labs and i-Human or case-based activities

Length: Approximately 1–2 pages of single-spaced SOAP documentation for one focused episodic encounter

Weighting: Approximately 5–10% of the course grade (typically one of several system-based lab assignments)

The purpose of this lab assignment is to demonstrate accurate, concise clinical documentation of a focused skin assessment using the SOAP (Subjective, Objective, Assessment, Plan) format for a specific dermatologic condition.

Assignment Context

NURS 6512 emphasizes the development of advanced assessment and diagnostic reasoning skills across the lifespan. During Week 4, students focus on skin, hair, and nail assessment, where precise lesion description, distribution patterns, and associated symptoms are essential for developing accurate differential diagnoses. This lab assignment uses a provided case graphic, vignette, or simulation scenario to practice structured SOAP documentation and clinical reasoning.

Learning Outcomes Assessed

• Apply advanced history-taking and physical examination techniques for skin, hair, and nail conditions.

• Use precise clinical terminology to describe abnormal skin findings.

• Formulate appropriate differential diagnoses based on subjective and objective data.

• Document a focused episodic encounter using SOAP note format consistent with advanced practice expectations.

Preparation

1. Review Week 4 learning resources related to skin, hair, and nail assessment, including required textbook chapters and dermatologic atlases.

2. Review SOAP note documentation guidelines and the Comprehensive SOAP Note Template provided in the course or program repository.

3. Carefully examine the assigned skin condition graphic, case vignette, or i-Human scenario designated for this week.

Task Description

Case Selection

Your instructor will assign a specific skin condition case or graphic or instruct you to select one from a numbered image set. Follow course directions precisely. In your SOAP note, clearly identify the case or graphic using its assigned number or brief descriptor (for example, Skin Condition Graphic #4: Annular erythematous plaques on trunk).

SOAP Note Requirements

Using the SOAP format, document a focused episodic visit for the selected skin condition. This assignment is not a narrative essay. Use clear section headings for Subjective, Objective, Assessment, and Plan.

Subjective (S)

• Chief Complaint (CC): Document the patient’s primary concern using their own words when possible (for example, “Itchy rash on arms for three days”).

• History of Present Illness (HPI): Provide a concise, organized description using standard descriptors such as location, onset, duration, characteristics, aggravating and relieving factors, associated symptoms, and treatments tried.

• Relevant Review of Systems (ROS): Include targeted ROS elements related to skin, hair, nails, and any associated systems (for example, fever, joint pain, gastrointestinal or respiratory symptoms) relevant to the case.

• Pertinent history: Include relevant past medical history, medications, allergies, and social history affecting skin health (for example, travel, occupational exposures, sexual history when appropriate, or immunosuppression).

Objective (O)

• Vital signs (if provided or appropriate to the scenario).

• Focused physical examination findings related to skin, hair, and nails.

• Accurate lesion description using clinical terminology (for example, macule, papule, plaque, vesicle, pustule), including size, color, shape, borders, distribution, configuration, and secondary changes.

• Documentation of pertinent normal findings and notable negatives.

Assessment (A)

• Identify a primary (working) diagnosis that best explains the subjective and objective findings using appropriate diagnostic terminology.

• List at least two reasonable differential diagnoses and briefly justify each based on lesion characteristics, distribution, associated symptoms, and risk factors.

• Do not include laboratory or imaging results unless provided; diagnostic testing may be proposed in the Plan section if required.

Plan (P)

Follow your course instructions regarding inclusion of the Plan section. If required, include only high-level elements:

• Diagnostics: Tests or referrals needed to confirm the diagnosis.

• Treatment: Initial management strategies such as topical or systemic therapies, patient education, and non-pharmacologic measures.

• Follow-up: Expected timeframe and criteria for reassessment or escalation of care.

Documentation and Submission Requirements

• Length: Approximately 1–2 pages of SOAP documentation; clarity and precision are expected at the graduate/APRN level.

• Format: Use SOAP headings and concise clinical bulleting as permitted by your program’s documentation standards.

• Terminology: Apply correct clinical terminology consistent with required textbooks and course exemplars.

• Citation: Formal citation within the SOAP note is minimal; reference diagnostic criteria or guidelines only when directly applied.

• Submission: Upload to the Week 4 Lab Assignment link by the posted deadline.

Marking Criteria (Week 4 SOAP Note – Skin Conditions Rubric)

Use of SOAP Format (20%)
Evaluates correct and consistent use of SOAP structure and section labeling.

Subjective Data (20%)
Assesses relevance, organization, and completeness of history and review of systems.

Objective Data and Clinical Terminology (20%)
Evaluates accuracy and precision of lesion descriptions and physical examination findings.

Assessment and Differential Diagnosis (25%)
Assesses appropriateness and justification of the primary diagnosis and differentials.

Clarity, Organization, and Professional Writing (15%)
Evaluates overall clarity, organization, and graduate-level clinical documentation quality.

Clinicians who develop skill in writing focused, accurate SOAP notes for common skin conditions gain a practical advantage in advanced practice. The discipline of naming lesion types, locations, and configurations enhances diagnostic reasoning and supports clearer communication among providers. A well-structured skin SOAP note centered on a single chief complaint creates a more clinically useful record than extended narrative documentation, as it directly aligns subjective history with objective findings relevant to everyday primary care practice (Ball et al., 2019).
https://evolve.elsevier.com/cs/product/9780323510806

Accurate dermatologic assessment relies not only on visual inspection but also on systematic documentation that supports pattern recognition and diagnostic accuracy. Research indicates that structured clinical documentation, such as SOAP notes, improves diagnostic consistency and reduces ambiguity when managing common skin disorders in primary and specialty care. Using standardized terminology and differential reasoning frameworks helps advanced practice nurses distinguish between inflammatory, infectious, and neoplastic skin conditions while supporting safe, evidence-based decision-making (Habif, 2016).

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S. and Stewart, R. W. (2019) Seidel’s Guide to Physical Examination: An Interprofessional Approach. 9th edn. St. Louis, MO: Elsevier. Available at: https://evolve.elsevier.com/cs/product/9780323510806

• Bickley, L. S. (2021) Bates’ Guide to Physical Examination and History Taking. 13th edn. Philadelphia, PA: Wolters Kluwer.

• Habif, T. P. (2016) Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 6th edn. Philadelphia, PA: Elsevier.

• Sullivan, D. D. (2019) Guide to Clinical Documentation. 3rd edn. Philadelphia, PA: F.A. Davis.

• American Association of Nurse Practitioners (2020) Standards of Practice for Nurse Practitioners. Available at: https://www.aanp.org/practice/clinical-resources

• Usatine, R. P., Smith, M. A., Chumley, H. S. and Mayeaux, E. J. (2020) The Color Atlas and Synopsis of Family Medicine. 3rd edn. New York, NY: McGraw-Hill Education.