Using the case bellow and the template as a guide create a SOAP note using APAP 7 format and scholarly references no older than 5 years.
October 10, 2024October 10, 2024
Discipline: Nursing
66-year-old female with a history of HTN, GAD, skin melanoma who came for a first tie consultation , she states she changed insurances recently and needs new doctor for her refills. oon the physical examination there is evidence of a lesion on the left side of her face asymmetrical, with irregular border, changes on coloration and with elevation, she states she noticed since a while but has not been able to take a look at it. Patient education was provided, referral to dermatologist to consider skin biopsy recommended as soon as possible, we sent refill for medications.
Dx: L89.9
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