Ideal Medical Scribe Chart - Example Medical Documentation - Skin Rash/Lesion - Provider's SOAP Note

Perfect medical scribe practice chart demonstrating how to complete a complex physician's note. This SOAP note is a demonstration of a Virtual Patient Scenario (VPS) for a patient being seen for a skin rash and lesions, and shows real-time how a medical document is completed. This includes the Subjective (CC, HPI, PFSH, ROS), Objective (PE, Diagnostic Studies), Assessment and Plan (MDM)- SOAP.
For additional resources, visit: www.scribeconn...

[@infoRN03]

Chief Complaint: Pruritic lower back rash persisting for 3 weeks Hx of Present Illness : The patient is a 65-year-old female with a complaint of pruritic lower back rash for 3 weeks after going to the beach. She noticed that it exacerbated over the last week, especially in the morning, and tried to manage it with cortisone and a hot compress to alleviate the itching and irritation. The patient has a history of regular dermatological check-ups with Dr. Yu, which she schedules annually. Her next dermatologist appointment is set for six months from now.

[@dons336]

Thank you!!!!

[@behappywithrinu]

👍