Description
A thorough skin assessment gives you important information about potentially serious diseases, especially in older adults who are vulnerable to skin breakdown. Students will perform the subjective and objective part of the “SO” of the soap note this week. Please take a look at the checklist to help you organize your methodology when performing the dermatologic physical exam, KEEPING IN MIND THAT YOU WILL BUILD UPON EVERY BODY SYSTEM WITH EACH MODULE UNTIL YOU CAN ACCURATELY PERFORM A COMPREHENSIVE PHYSICAL EXAM BY THE END OF THIS COURSE.Remember to practice on an adult patient.Use the guide below to help you hit all the points you need. Students will build upon the below checklist each week. It is up to the student to determine how to perform the final head-to-toe assessment at the end of the semester.
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NURS 756 Skin, Hair, & Nails “SO”ap Note Template
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
REVIEW OF SYSTEMS
• Constitutional
• Integumentary
• Eyes
• ENT
• Neck/lymph
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Endocrine
• Hematological
• Neurologic
• Psychiatric
PAST MEDICAL HISTORY
SURGICAL HISTORY
MEDICATIONS
ALLERGIES
FAMILY HISTORY
SOCIAL HISTORY
PHYSICAL EXAMINATION
Vital Signs
• Constitutional
• Integumentary
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NURS 756 Skin, Hair, & Nails “SO”ap Note Template
PMP Instructions
Chief Complaint – brief statement of the patient’s own words. This is the reason why the patient
is coming to see you and is the only part of the charge allowed to be in quotations. Example:
“My throat hurts.”
History of Present Illness – this is a detailed interview prompted by the chief complaint or
presenting symptom. It is written in narrative (paragraph) form and is subjective. Since this is
subjective information, and it is written in words that a patient would say. For example, most
patients would say dizziness rather than vertigo. It should be in logical order. Many providers
use a system to help them remain consistent in their interview questions, such as OLDCARTS.
Using a system every time helps you not miss important information. You then need to add any
pertinent positives or negatives. Example: XX is an 18-year-old female with a 3-day
complaint of sore throat. She describes it as a burning sensation that has been constant
since the onset. It worsens with swallowing, and rates it a 9/10. She has taken Tylenol,
which hasn’t helped. Her last dose was at 0800. She denies body aches, fevers, chills,
headache, ear pain, runny/stuffy nose, cough, shortness of breath, facial/chest congestion,
abdominal pain, N/V, or unusual skin rash. THE HPI NEEDS TO BE AS THOROUGH AS
POSSIBLE. Points will be deducted if medical terminology is used in the HPI.
•
HINT: Onset/location/duration/characteristics/alleviating & aggravating
factors/radiating and relieving factors/timing/severity/pertinent +/-.
Review of Systems – the ROS is comprehensive or focused depending on why the patient is
coming to see you. You will need to decide which body systems are pertinent to your patient’s
presentation. Points will be deducted for inappropriate documentation for body systems that are
not pertinent to your patient or incomplete systems that are pertinent. Please take the time to
think about why you are asking specific questions about your patient. For the ROS, students are
to state if a patient “DENIES” or “COMPLAINS OF.” Using statements such as “all review of
systems are negative unless noted in the HPI” or using terms such as “negative for” or “positive
for” will not be accepted. Points will be deducted if medical terminology is used in the ROS.
Remember, the ROS is subjective information and should be documented using the patient’s
words (not yours).
•
Body Systems
o Constitutional
o Eyes
o ENT
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NURS 756 Skin, Hair, & Nails “SO”ap Note Template
o
o
o
o
o
o
o
o
o
o
o
Neck/lymph
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Endocrine
Hematological
Neurologic
Psychiatric
Past Medical History – this is the total sum of a patient’s health status before the presenting
problem. Document birth history for new patients that are less than 5 years of age. Bullet point.
Surgical History – this is the total sum of a patient’s surgical history. Bullet point.
Current Medications – include dosing, frequency, and reason for all prescriptions, OTCs,
CAMs, etc. Pertinent immunization history goes in this section of the chart. Bullet point.
Allergies – includes medication and food with reaction. Bullet point.
Family History – family history helps risk-stratify patients with conditions and genetic links. It
provides information to the provider for early warning signs of disease. Anticipatory guidance
can be developed from the family history. Family history includes 1st, 2nd, and 3rd generation
relatives. Students need to add the age of all relatives (age at the time of death for the deceased)
and any presence of chronic diseases. Bullet point.
Social History – broad category of the patient’s medical history that includes smoking, vaping,
other tobacco use, alcohol, drug use, relationship status, occupation, hobbies, developmental,
school, work, and sexual activity (including the number of partners and male/female/or both).
Bullet point.
Physical Exam – the physical exam is comprehensive or focused depending on why the patient
is coming to see you. The patient’s vital signs, height, weight, and BMI should be listed at the
beginning of your physical exam. You will need to decide which body systems are pertinent to
your patient’s presentation. Points will be deducted for inappropriate documentation for body
systems that are not pertinent to your patient or incomplete systems that are pertinent. Please take
the time to think about why you are asking specific questions about your patient.
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NURS 756 Skin, Hair, & Nails “SO”ap Note Template
This part of the exam is objective. Your documentation needs to reflect medical terminology.
Points will be deducted if “layman” terms are used in this section or if “complaints of or denies”
documentation is found the physical exam.
•
Body Systems
o Constitutional
o Integumentary
Revised 1/2024
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Skin, Hair, * Nails “SO”ap Note Rubric
Required Documentation
Points
Chief Complaint (In the
patient’s own words with
quotations)
1
History of Present Illness (HPI)
– this section should be
systematically developed
including pertinent +/- and
associated symptoms
15
Review of Systems (ROS) – body
systems relevant to focused
visit
5
Past Medical History (PMH)
2
Surgical History
2
Medications – dosage,
frequency, indication (including
supplements, CAMs, and OTCs)
2
Allergies – medication, food,
environmental with reaction
2
Family History (FH)
3
Social History (SH)
5
Physical Exam (PE) – body
systems relevant to focused
visit
10
Grammar / Mechanics / APA
References & Citations
3
Total Points
50
Revised 1/2024
Comments
Detailed Skill Performance Evaluation: Skin, Hair, and Nails Examination
Directions: You will have 10 minutes to complete the skill. All critical (C) steps and 80% of the noncritical steps
must be performed or verbalized. Special tests (S) will be performed if requested by the examiner.
Start:
End:
Performed
Verbalized
Washes hands FIRST and dons appropriate personal protective equipment.
C
Introduces self to patient using first and last name, including role.
Y/N
Notes general appearance and vital signs.
Y/N
Inspection (Students can combine inspection and palpation for a better exam flow.)
1. Assess color: erythema, pallor, cyanosis, or jaundice (Pallor: Look at fingernails, lips,
mucous membranes; palms and soles in dark-skinned people. Cyanosis: Look at lips, oral
mucosa, tongue, nails, hands, feet. Jaundice (yellowing): Look at sclerae, conjunctivae, lips,
hard palate, tongue, and skin in general [need penlight].)
2. Look for areas of hypo- or hyperpigmentation (Examine upper and lower extremities,
trunk, and face.)
3. Scalp hair: assess distribution and quantity and examine any scalp lesions (Look at head
and scalp; must part hair.)
4. Nails/nail beds: note color, shape, and any lesions (Look at finger and toe nails and note
condition in all four extremities.)
5. Note characteristics of any lesions: color, location, distribution, pattern, size (in mm),
shape, and type (Look for lesions on trunk and extremities including palms and soles.)
Identify any nevi and apply the ABCDE method to screen for melanoma: Asymmetry,
Borders, Color, Diameter, Evolution
Palpation
1. Skin temperature: check for localized or generalized warmth or coolness (Feel upper and
lower extremities [anterior and posterior] with back of hands; must include fingers and
toes.)
2. Check skin moisture and texture (Feel upper and lower extremities [anterior and
posterior] with fingertips; must include fingers and toes.)
3. Assess skin turgor (Pinch skin over one dorsal hand.)
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
4. Palpate hair texture (Palpate hair in at least two places.)
Y/N
Y/N
5. Palpate fingernails and toenails
Y/N
Y/N
Adequate exposure was for all inspection steps.
C
Adequate draping was maintained for all steps.
Evaluation: #Y =
#C =
min. = 18/23 min. = 3
C
Comments on quality of performance:
Needs remediation?
Y/N
Student:
Evaluator:
Date:
Developed by Albany Medical College, Center for Physician Assistant Studies | Bickley: Bates’ Guide to Physical Examination
and History Taking, Thirtheenth Edition. Copyright © 2021 Wolters Kluwer Health
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