NURS 6512: Advanced Health Assessment

Week 4 Assignment – Focused SOAP Note and Differential Diagnosis

Course and Assessment Metadata

Course code/title: NURS 6512 – Advanced Health Assessment (graduate advanced practice core, Shadow Health integration)

Program level: MSN / APRN

Assessment label: Week 4 Assignment 1 – Focused SOAP Note (Assessment Task 2)

Assessment type: Individual patient case documentation using SOAP note template

Length requirement: 2–3 page focused SOAP note (approximately 800–1,200 words, excluding template headers), completed on assigned Shadow Health virtual patient or instructor case

Weighting: 25% of course grade (local program may adjust)

Submission format: Typed SOAP note using provided template, APA 7th ed. references, LMS submission

Assignment Overview

Advanced health assessment courses require structured SOAP documentation to develop diagnostic reasoning and clinical decision making. In Week 4, you will complete a focused assessment on an assigned adult patient case, generate a prioritized differential diagnosis list with supporting rationale, and propose an evidence-based management plan. The goal is to demonstrate concise yet comprehensive documentation that reflects graduate-level advanced practice expectations.

Focused SOAP notes require the clinician to synthesize subjective and objective findings into clear clinical judgments. Effective documentation reflects accurate data gathering, pattern recognition, and prioritization of potential diagnoses based on likelihood and risk. Diagnostic reasoning at the graduate level requires linking findings directly to pathophysiology and clinical guidelines, ensuring that the assessment and plan align with current evidence-based standards (Ball et al., 2023).

Learning Outcomes

On successful completion, you will be able to:

• Conduct and document a focused history and physical examination using appropriate clinical terminology.

• Synthesize subjective and objective data to generate a prioritized differential diagnosis list, including the most likely condition and a worst-case scenario.

• Formulate an evidence-based assessment and plan that addresses diagnostic testing, treatment, and patient education.

• Demonstrate graduate-level clinical reasoning in a structured SOAP note format suitable for electronic health records.

Case Assignment

Your instructor assigns a specific Week 4 case profile, such as a skin condition graphic, abdominal pain presentation, chest discomfort scenario, or neurological complaint, via course announcements or the Shadow Health platform. You must complete the focused assessment, documentation, and reasoning based strictly on the assigned case.

Example Case (For Reference Only – Use Your Assigned Case)

A 28-year-old African American woman presents with a three-week history of pruritic rash on bilateral inner thighs and groin, worsening with heat and friction. She denies systemic symptoms but reports mild tenderness on palpation.

Task Instructions

Use the provided Focused SOAP Note Template. Document findings clearly under each SOAP heading. Use clinical terminology and briefly justify diagnostic reasoning where required.

Subjective (S)

Include:

• Patient demographics (age, gender, ethnicity, occupation).

• Chief complaint in the patient’s own words.

• History of present illness using OLDCARTS or PQRST framework:

  • Onset

  • Location

  • Duration

  • Characteristics

  • Aggravating and alleviating factors

  • Timing

  • Severity

• Relevant past medical history.

• Medications and allergies.

• Social history.

• Family history.

• Focused review of systems related to the presenting concern.

Objective (O)

Include:

• Vital signs and general appearance.

• Focused physical examination findings using precise descriptors:

  • Inspection

  • Palpation

  • Percussion

  • Auscultation

• Pertinent negatives.

• Diagnostic tests performed, if applicable (labs, imaging, point-of-care tests).

Assessment (A)

Include:

• Three to four differential diagnoses, ranked in order of likelihood.

• At least one potential life-threatening or worst-case condition.

• One to two sentence rationale for each diagnosis, linking subjective and objective data.

• Clear statement of the most likely diagnosis.

Plan (P)

Include:

• Diagnostic tests or orders with rationale.

• Therapeutic interventions such as medications, referrals, or procedures.

• Patient education.

• Follow-up plan with timeframe.

• Health promotion and prevention strategies.

Formatting and Academic Integrity

• Length: 2–3 pages total using the SOAP template without unnecessary expansion.

• Style: Professional clinical language. APA 7th edition for references.

• References: Typically 2–3 scholarly sources.

• Template: Use the provided course template without altering structure.

• Integrity: Base documentation strictly on assigned case data. Do not fabricate information or introduce external patient details.

Analytic Scoring Rubric – Focused SOAP Note

Evaluation focuses on completeness, diagnostic reasoning strength, documentation clarity, and plan appropriateness.

Subjective Section (25 points)

• Exemplary (23–25): Complete demographics; full OLDCARTS; chronological and detailed HPI; focused ROS and comprehensive relevant history with pertinent negatives.

• Advanced (20–22): Minor omissions in HPI or history.

• Intermediate (17–19): Missing one or two HPI elements; history insufficiently focused.

• Novice (≤16): Vague complaint; significant history gaps.

Objective Section (30 points)

• Exemplary (27–30): Complete vitals and focused examination; precise terminology; includes pertinent negatives.

• Advanced (24–26): Minor technique omission.

• Intermediate (21–23): Missed one or two areas or vague descriptors.

• Novice (≤20): Multiple examination gaps or inaccuracies.

Assessment Section (20 points)

• Exemplary (18–20): Three to four logically ranked differentials including worst-case; each supported by data; most likely diagnosis clearly identified.

• Advanced (16–17): Strong differentials with one weak rationale.

• Intermediate (14–15): Limited differentials or insufficient justification.

• Novice (≤13): Unsupported or inappropriate differentials.

Plan Section (15 points)

• Exemplary (14–15): Diagnostics, treatment, education, and follow-up are comprehensive, prioritized, and evidence-based.

• Advanced (12–13): One component missing.

• Intermediate (10–11): Plan incomplete or poorly prioritized.

• Novice (≤9): Plan unsafe or largely absent.

Documentation and Scholarly Quality (10 points)

• Exemplary (9–10): Logical SOAP structure; accurate clinical terminology; correct APA formatting; concise and within length limits.

• Advanced (8): Minor errors.

• Intermediate (7): Several terminology or APA issues.

• Novice (≤6): Disorganized or multiple major errors.

(Model SOAP Segments – Not for Submission)

Subjective:
Patient is a 28-year-old African American female office worker presenting with a pruritic rash on bilateral inner thighs and groin folds for three weeks. Rash began as small red spots after a hot yoga class and progressed with increased itching, particularly after sweating or wearing tight clothing. Denies fever, weight loss, joint pain, or respiratory symptoms. Uses topical hydrocortisone intermittently without improvement. No known drug allergies. Takes daily multivitamin. No family history of skin cancer.

Objective:
Vitals stable (BP 118/76, HR 72, RR 16, Temp 98.6°F). Skin examination reveals symmetrical erythematous plaques with scale and satellite pustules in inguinal folds and upper inner thighs. Mild excoriations present. No induration, fluctuance, or regional lymphadenopathy. No mucosal involvement.

Assessment:

1. Intertrigo with candidal superinfection, most likely due to moist skin folds and classic satellite lesions.

2. Contact dermatitis, possible irritant from sweat or clothing.

3. Tinea cruris, dermatophyte infection presenting with erythematous plaques.

4. Cellulitis, worst-case scenario though less likely given absence of fever or spreading erythema.

Most likely diagnosis: candidal intertrigo (Ball et al., 2023).

Plan:
Perform KOH preparation and fungal culture if indicated. Initiate topical antifungal such as clotrimazole twice daily for two weeks. Advise moisture control, loose cotton clothing, and hygiene measures. Consider oral antihistamine for pruritus if needed. Follow up in one week or sooner if symptoms worsen.

Resources

Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S. and Stewart, R.W., 2023. Seidel’s guide to physical examination. 10th ed. St. Louis: Elsevier.

Murphy, M.B., Rosenberg, E., Aban, I. and Kovarik, C.L., 2021. Intertrigo and secondary skin infections. American Family Physician, 103(9), pp.539–546.

Usatine, R.P. and Riojas, M., 2019. Diagnosis and management of interdigital tinea pedis and intertrigo in the primary care setting. Journal of the American Academy of Dermatology, 81(5), pp.AB120.

Kottner, J., Blume-Peytavi, U., Lohrmann, C. and Halfens, R., 2018. Associations between individual characteristics and incontinence-associated dermatitis. International Journal of Nursing Studies, 78, pp.70–78.

Eichenfield, L.F. et al., 2014. Guidelines of care for the management of atopic dermatitis. Journal of the American Academy of Dermatology, 71(6), pp.1168–1193.

Bickley, L.S., 2021. Bates’ guide to physical examination and history taking. 13th ed. Philadelphia: Wolters Kluwer.