Posted: July 9th, 2022

Write A Focused Soap Note: Atopic Dermatitis

Write A Focused Soap Note

A mother brings her 14-year-old daughter to the clinic because of a persistent facial rash that has been present for 3 to 4 weeks. The child is restless at night and scratches in her sleep. She is otherwise healthy. Physical examination reveals a well-nourished, healthy-appearing girl with dry, red, scaly areas on the cheeks, chin, chest, and around the mouth, as well as on the extensor surfaces of her extremities. The areas on the cheeks have a plaque-like, weepy appearance with papules. The remainder of the child’s examination is normal. Atopic Dermatitis
Focused SOAP Checklist

SUBJECTIVE:
o Chief Complaint: Did I state briefly in the patient’s own words
o History of present illness: Did I write a paragraph in the order of the 7 attributes & did I put the 7 attributes in a concise list in the chart (OLD CART-if you don’t know it, please look it up)
o Medications: did I list each medication and reason.
o Allergies: Did I include specific reactions to medications, foods, and insects, environmental?
o Past Medical History (PMH): Did I list all the patient Illnesses, hospitalizations? Did I Include childhood illnesses
o Past Surgical History (PSH): Did I list the dates, indications and types of operations?
o OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function.
o Personal/Social History: Tobacco use, Alcohol use, Drug use, risky sexual behavior. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history, school/daycare etc
o Immunizations: Did I include Last Tdap, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age) HPV if applicable
o Family History: Did I list for Parents, Grandparents, siblings, children?
o Review of Systems (SUBJECTIVE DATA): Did I include the systems related to my Chief Complaint and chronic conditions? Did I type detailed description? I did NOT use WNL. I was specific in my descriptions (see health assessment textbook). Did I remember this is what the patient says and not what I observed? Did I include the cardiovascular and respiratory system regardless of chief complaint?
Physical Exam: (OBJECTIVE DATA) This is what YOU see/touch/hear/smell
o Did I list the vital signs as the first thing in the objective section? Did I include the BMI for adults? Did I include the percentile for the ht, wt, bp etc for pediatrics?
o Did I examine the systems that are pertinent to the CC, HPI, and History. Did I describe what I observed? Did I never use WNL or normal? Did I describe what I observed during the physical exam?
o Did I include the systems in a list format?
o Did I include cardiovascular and respiratory systems regardless of cc?
o Did I delete the systems I did not review?

ASSESSMENT:

o Did I put my priority diagnosis in bold for EACH CC?
o Did I include at least 3 differentials(DD) after the priority diagnosis for EACH of my CC?
o Did I explain what each DD is, use references to explain and tell how you ruled in or ruled out each DD? (AND does your ROS and PE reflect this?)
o Did I include a reference citation for each diagnosis under the assessment area?
o Are my assessments concise and in a chart format?
o Did I put my differential diagnosis in order by priority?
o Did I provide a detailed rationale for each diagnosis?

Holistic care:

o Did I cover existing diagnoses and whether any changes need to be made?
o Did I include needed preventative care based on my patient’s age and risk factors?

PLAN:
o Did I include a treatment plan?
o Did I address if labs, x-rays, etc. were needed?
o Did I include a pharmacological plan and citation for EBP?
o Did I include non-pharmacological strategies?
o Did I discuss alternative therapies if applicable?
o Did I state when the patient needs a follow-up?
o Did I indication if any referrals or consultations were necessary or not necessary?
o Did I write a rationale based on evidence?
o Health Promotion: Did I address this area? Did I state what the patient/ family need to do to promote their health based on the USPTF for adults or Bright Futures for children? Did I document my citations?
o Disease Prevention: Did I do these based on recommendations from USPTF for adult’s or Bright Futures for children based on the patient’s age? Did I state what needs to be done to detect disease early…fasting lipid profile, mammography, colonoscopy, immunizations, etc? Did I cite the source?

REFLECTION:
o Did I state what I learned from this experience?
o Did I state what I would you do differently or if I would do everything the same and the rationale?
o Did I state if I either agreed or disagreed with my preceptor based on evidence (and cite references for EBP?
o Did I state what I would do if the person was insured versus if the person was not insured? Indicate how this would change your plan.
o Did I state the community resources in my area?
APA
o Do I have a minimum of 3 scholarly journal articles? (NONE OF WHICH ARE PATIENT EDUCATION SITES THAT I GOOGLED)
o Did I use at least 3-4 course resources?
o Do I have the paper in a neat format?
o Did I list my references in APA format?

Developed by NP. Revision DNP, APRN, FNP-BC
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-Sample Answer-
SUBJECTIVE:

Chief Complaint: Persistent facial rash for 3-4 weeks

History of present illness: 14-year-old girl presents with dry, red, scaly areas on the cheeks, chin, chest, and around the mouth, as well as on the extensor surfaces of her extremities. The areas on the cheeks have a plaque-like, weepy appearance with papules. The rash has been present for 3-4 weeks and the patient reports being restless at night and scratching in her sleep.

Medications: None

Allergies: None

Past Medical History (PMH): No significant medical history

Past Surgical History (PSH): None

OB/GYN History: N/A

Personal/Social History: The patient is otherwise healthy and reports no tobacco, alcohol, or drug use. She is currently in school and reports no difficulties with activities of daily living or instrumental activities of daily living. She reports no exercise routine or specific eating habits.

Immunizations: Up to date on all immunizations according to age-appropriate schedule

Family History: No significant family medical history

Review of Systems (SUBJECTIVE DATA): No significant findings in any systems other than skin.

PHYSICAL EXAM (OBJECTIVE DATA):

Vital signs: Normal
Skin: Dry, red, scaly areas on the cheeks, chin, chest, and around the mouth, as well as on the extensor surfaces of the extremities. Plaque-like, weepy appearance with papules on the cheeks. No other abnormalities noted.

ASSESSMENT:
Priority diagnosis: Atopic Dermatitis
Differential diagnoses: Contact dermatitis, seborrheic dermatitis, psoriasis
Atopic dermatitis is a likely diagnosis based on the patient’s presentation of a persistent facial rash with dry, red, scaly areas and papules on the cheeks. The rash has also been present for several weeks, which is consistent with atopic dermatitis. Contact dermatitis and seborrheic dermatitis are both considered as differential diagnoses due to the presence of a rash on the face, but the absence of specific triggers or involvement of other areas of the body make these less likely. Psoriasis is also considered as a differential due to the presence of scaly lesions, but the lack of plaques and involvement of other areas of the body make this less likely.
Holistic care:
The patient’s atopic dermatitis is currently being managed with skin care measures such as moisturizers and avoiding triggers. No changes to current management are necessary at this time.
PLAN:
Recommend over-the-counter hydrocortisone cream to be applied to the affected areas twice daily for 2 weeks.
Recommend the use of a mild, fragrance-free soap and daily moisturization.
Recommend avoiding known triggers, such as harsh soaps and extreme temperatures.
Recommend follow-up appointment in 2 weeks to assess response to treatment.
Health Promotion:
Discuss the importance of proper skin care and avoiding known triggers to help prevent flare-ups of atopic dermatitis.
Encourage the patient to continue with regular health maintenance visits to monitor for any new or persistent skin concerns.
References:
Atopic Dermatitis. (n.d.). American Academy of Dermatology. Retrieved from https://www.aad.org/public/diseases/eczema/atopic-dermatitis
Contact Dermatitis. (n.d.). American Academy of Dermatology.

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