Dermatology Clinic SOAP Note

Date of Service: [date]

Patient: [patient name and identifiers]

Provider: [clinician name, credentials]

Encounter Type: [new / established]; [in-person / telehealth]

Source of History: [patient / caregiver / chart / other]

Subjective

Chief Complaint: [patient-stated reason for visit]

HPI: [Narrative description of onset, duration, course, symptoms (pruritus, pain, bleeding), anatomic distribution and spread pattern, suspected triggers/exposures, prior treatments and response, and history of similar episodes. For lesion evaluations, include patient-noted changes and timeline.]

Relevant History: [pertinent dermatologic history only: personal/family history of skin cancer, atopic history, immunosuppression, pregnancy status if teratogenic medications considered] (Include only if relevant to today's visit; otherwise omit.)

Medications: [current dermatology-relevant medications with name, strength, route, frequency; adherence and adverse effects when pertinent] (Omit if not applicable.)

Allergies: [drug and reaction] (If allergy history cannot be obtained, document: "Allergy history not obtained.")

ROS: [targeted review pertinent to skin condition and systemic features influencing the differential] (Include only if performed; otherwise omit.)

Objective

Exam Scope: [focused / limited / total body skin exam (TBSE)] (Note any areas not examined and reason if relevant.)

Skin Exam: [findings organized by anatomic region or by problem] (Use dermatologic descriptors: anatomic site with laterality, number, size in mm/cm for lesions of concern, primary morphology, color, border/demarcation, surface changes, configuration, distribution. Include dermoscopy findings when applicable. Use objective descriptors rather than diagnostic labels.)

Other Exam: [scalp/hair, nails, mucosa, lymph nodes, vascular findings as relevant] (Omit if not examined.)

Data Reviewed: [labs, cultures, KOH, pathology results, outside records, patient-submitted photos with source and date] (Omit if none.)

Assessment

(Number problems in priority order. For each, include diagnosis or working diagnosis, status, brief supporting rationale, and differential if uncertainty exists. Include severity measures such as BSA%, lesion size, or validated scores when relevant.)

1. [Problem]: [diagnosis] — [new / flaring / improved / stable]. [Brief rationale referencing key findings; differential diagnoses if uncertain.]

Plan

(Organize by problem number to match Assessment.)

1. [Problem Plan]: [therapy with formulation, strength, dose, frequency, duration, application site, and key counseling; diagnostics ordered; patient education provided; monitoring requirements; follow-up timeframe]

Procedure (if performed): [indication] — [exact anatomic site with laterality, lesion size]. Informed consent obtained. [technique, anesthesia agent/amount, hemostasis/closure method]. Specimen labeled and sent to pathology. Complications: [none / describe]. Wound care instructions and return precautions provided; results follow-up plan discussed. (If billing E/M separately on procedure day, ensure documentation demonstrates significant, separately identifiable evaluation/management service.)

Orders: [prescriptions, labs, pathology orders, referrals] (Omit if none.)

Follow-up: [timeframe per problem, results communication plan, return precautions]

(If visit level selected by time: Total clinician time: [minutes])