Dermatology: Step-by-Step Guide on How to Write SOAP Notes

Updated January 2026

Dermatology documentation presents unique challenges that distinguish it from other medical specialties. The visual nature of skin conditions requires precise, standardized descriptive terminology that can accurately convey findings to other providers without requiring images. Effective dermatology SOAP notes must capture lesion morphology, distribution patterns, and clinical context while supporting diagnostic accuracy and treatment planning.

This guide provides comprehensive instructions for documenting dermatological encounters, from initial patient presentation through treatment outcomes. Whether you're evaluating a suspicious nevus, managing chronic psoriasis, or performing procedural dermatology, mastering dermatology-specific documentation will enhance patient care, support accurate coding, and ensure medical-legal protection.

What Makes Dermatology Documentation Unique

Dermatology differs from other specialties in several key documentation aspects:

1. Visual Documentation Dependency: Skin findings must be described with enough precision that another clinician could visualize the lesion without seeing it
2. Standardized Morphological Terminology: Use of specific dermatological vocabulary (papule, plaque, macule, etc.) is essential
3. Photography Integration: Clinical photography has become standard of care for many conditions
4. Body Surface Area Calculations: Many conditions require BSA documentation for severity assessment and treatment decisions
5. Procedural Documentation: High volume of biopsies, excisions, and cosmetic procedures require detailed documentation

Subjective Section (S)

In a dermatology SOAP note, the Subjective section captures the patient's description of their skin concern, relevant history, and symptom characteristics. This section provides critical context for clinical decision-making.

Subjective Section (S) Components

1. Chief Complaint:

   • The primary skin concern bringing the patient to the visit
   • Example: "I have a new mole on my back that has been changing over the past three months."

2. History of Present Illness (Lesion History):

   • Onset: When the lesion first appeared or was noticed
   • Duration: How long the condition has been present
   • Evolution: Changes in size, shape, color, or symptoms over time
   • Previous treatment: Prior therapies attempted and their outcomes
   • Example: "The patient noticed a small brown spot on the upper back approximately 6 months ago. Over the past 3 months, it has grown larger, developed irregular borders, and occasionally bleeds with minor trauma."

3. Associated Symptoms:

   • Pruritus (itching): Severity (scale 0-10), timing, aggravating factors
   • Pain or tenderness: Character, intensity, triggers
   • Burning or stinging: Associated activities or exposures
   • Bleeding or drainage: Frequency, spontaneous vs. trauma-induced
   • Example: "The patient reports moderate itching (5/10) that worsens at night and with hot showers."

4. Environmental and Exposure History:

   • Sun exposure history: Lifetime exposure, tanning bed use, sunburn history
   • Occupational exposures: Chemicals, irritants, outdoor work
   • Recent travel: Endemic dermatoses, new exposures
   • Contact history: New products, detergents, fragrances, metals
   • Example: "The patient has a history of significant sun exposure from outdoor work as a construction worker for 25 years, with multiple blistering sunburns in childhood."

5. Skin Care Routine:

   • Current skincare products and frequency
   • Cleansers, moisturizers, prescription products
   • Recent changes in routine
   • Example: "Uses gentle fragrance-free cleanser daily, moisturizer twice daily. Recently started a new retinol product 2 weeks ago."

6. Personal and Family Skin History:

   • Personal history of skin cancer or precancerous lesions
   • Family history of melanoma or other skin cancers
   • History of atypical moles or dysplastic nevus syndrome
   • Autoimmune conditions affecting skin
   • Example: "Father diagnosed with melanoma at age 55. Patient has history of multiple atypical nevi requiring monitoring."

7. Review of Systems (Skin-Specific):

   • Hair changes: Loss, growth patterns, texture
   • Nail changes: Discoloration, thickening, separation
   • Mucous membrane involvement: Oral or genital lesions
   • Systemic symptoms: Fever, joint pain, fatigue (for inflammatory conditions)
   • Example: "Denies oral lesions, joint pain, or fever. Reports mild nail pitting on several fingernails."

8. Allergies:

   • Known allergies to topical medications
   • Contact allergens previously identified
   • Drug allergies with reactions
   • Example: "Allergic to neomycin (contact dermatitis), penicillin (hives)."

9. Current Medications:

   • Topical medications (prescription and OTC)
   • Systemic medications that may affect skin
   • Photosensitizing medications
   • Example: "Currently using hydrocortisone 1% cream PRN, takes hydrochlorothiazide 25mg daily for hypertension."

Tips for Dermatology Subjective Documentation:

• Document the timeline of lesion evolution in detail
• Record exact duration of symptoms when possible
• Include relevant phototype/Fitzpatrick skin type
• Note any photographic documentation obtained

Example of a Subjective Section for Dermatology

Objective Section (O)

The Objective section in dermatology requires precise, standardized terminology to describe skin findings. Accurate documentation allows other providers to understand the clinical picture and is essential for appropriate coding and medical-legal protection.

Objective Section (O) Components

1. Vital Signs (when relevant):

   • Blood pressure, heart rate (especially for procedures)
   • Temperature (for infectious or inflammatory conditions)
   • Example: "BP 128/82, HR 72, Temp 98.6F"

2. General Appearance:

   • Overall skin health assessment
   • Fitzpatrick skin type documentation
   • General photodamage assessment
   • Example: "Well-appearing male with Fitzpatrick type II skin, moderate photodamage on sun-exposed areas."

3. Primary Lesion Description: This is the core of dermatological documentation. Use the standardized approach:

   Morphology (Primary Lesion Type):

   • Macule: Flat, circumscribed color change under 1cm
   • Patch: Flat, circumscribed color change over 1cm
   • Papule: Elevated, solid lesion under 1cm
   • Plaque: Elevated, solid lesion over 1cm
   • Nodule: Palpable, solid lesion extending into dermis
   • Tumor: Large nodule over 2cm
   • Vesicle: Fluid-filled lesion under 1cm
   • Bulla: Fluid-filled lesion over 1cm
   • Pustule: Pus-filled lesion
   • Wheal: Transient, edematous papule or plaque

   Color:

   • Describe accurately: erythematous, hyperpigmented, hypopigmented, violaceous, brown, tan, black, pink, flesh-colored, white

   Size:

   • Measure in millimeters or centimeters
   • Use two dimensions for irregular lesions (e.g., 8mm x 6mm)

   Shape:

   • Round, oval, linear, annular, arcuate, serpiginous, irregular

   Border:

   • Well-defined, ill-defined, regular, irregular, notched

   Surface:

   • Smooth, rough, verrucous, scaly, crusted, ulcerated, eroded

4. ABCDE Criteria for Pigmented Lesions: When evaluating melanocytic lesions, document each criterion:

   • A - Asymmetry: Is the lesion asymmetric in shape?
   • B - Border: Are borders irregular, notched, or scalloped?
   • C - Color: Is color uniform or variegated (multiple shades)?
   • D - Diameter: Is the lesion >6mm?
   • E - Evolution: Has the lesion changed over time?

   Example: "ABCDE assessment: Asymmetric (+), Borders irregular with notching (+), Color variegated with dark brown, light brown, and black areas (+), Diameter 9mm (+), Evolution with growth over 3 months per patient (+). 5/5 ABCDE criteria positive."

5. Distribution and Configuration:

   Distribution Patterns:

   • Localized, generalized, symmetric, asymmetric
   • Sun-exposed areas, intertriginous, acral
   • Dermatomal, following Blaschko lines
   • Koebner phenomenon (if applicable)

   Configuration:

   • Discrete (individual lesions)
   • Grouped/clustered
   • Linear
   • Annular (ring-shaped)
   • Reticular (net-like)
   • Herpetiform

6. Secondary Changes:

   • Scale, crust, erosion, ulceration
   • Excoriation, lichenification
   • Atrophy, scarring
   • Telangiectasia

7. Dermoscopy Findings (when performed):

   • Document dermoscopic features observed
   • Pattern recognition findings
   • Specific structures (globules, dots, streaks, veil, network)
   • Example: "Dermoscopy reveals irregular pigment network, pseudopods at 3 and 7 o'clock positions, blue-white veil centrally, and atypical dots/globules."

8. Body Surface Area (BSA) Assessment:

   • Required for conditions like psoriasis, atopic dermatitis, vitiligo
   • Rule of 9s or hand-as-1% method
   • Example: "Psoriatic plaques involving approximately 12% BSA: back 5%, bilateral lower extremities 4%, scalp 2%, elbows 1%."

9. Photography Documentation:

   • Note when clinical photographs obtained
   • Location and number of images
   • Example: "Clinical photographs obtained: 2 overview images, 3 close-up images with ruler for scale, 2 dermoscopic images."

10. Regional Lymph Node Examination:

    • Required for suspected malignancy
    • Example: "No palpable lymphadenopathy in cervical, axillary, or inguinal regions."

Lesion Description Framework Template

Example of an Objective Section for Dermatology

Assessment Section (A)

The Assessment section synthesizes subjective and objective findings to formulate a clinical impression and differential diagnosis. In dermatology, this section must justify the diagnostic approach and any procedures planned.

Assessment Section (A) Components

1. Clinical Diagnosis/Impression:

   • Primary diagnosis or leading differential
   • Supporting clinical rationale
   • Example: "Atypical melanocytic lesion, concerning for malignant melanoma"

2. Differential Diagnosis:

   • List alternative diagnoses considered
   • Rank by likelihood when possible
   • Example: "Differential includes: 1) Malignant melanoma, 2) Severely dysplastic nevus, 3) Pigmented basal cell carcinoma"

3. Risk Assessment:

   • Patient risk factors for the suspected diagnosis
   • Risk stratification for skin cancer patients
   • Example: "High-risk for melanoma given family history, Fitzpatrick type II, significant sun exposure history, and multiple atypical nevi"

4. Severity Assessment:

   • For chronic conditions: mild, moderate, severe
   • Validated scoring systems when applicable (PASI for psoriasis, EASI for atopic dermatitis, IGA)
   • Example: "Moderate plaque psoriasis, PASI score 8.2"

5. Stage/Classification (when applicable):

   • Breslow depth and Clark level for melanoma
   • TNM staging when known
   • Example: "Pending histopathologic staging"

6. Response to Previous Treatment:

   • Efficacy of prior therapies
   • Tolerance and adverse effects
   • Example: "Failed topical corticosteroids and topical calcineurin inhibitors, partial response to narrow-band UVB"

7. Prognosis:

   • Expected disease course
   • Treatment expectations
   • Example: "Prognosis dependent on histopathologic findings; if melanoma confirmed, prognosis will depend on Breslow depth and staging"

Dermatological Diagnosis Approach

For systematic assessment, consider:

For Inflammatory Conditions:

• Acute vs. chronic
• Primary vs. secondary lesions
• Distribution pattern suggesting diagnosis
• Associated systemic features

For Neoplastic Conditions:

• Benign vs. malignant features
• Risk factors present
• Need for tissue diagnosis
• Staging requirements

For Infectious Conditions:

• Bacterial, viral, fungal, parasitic
• Culture/biopsy needs
• Transmission considerations

Example of an Assessment Section for Dermatology

Plan Section (P)

The Plan section outlines the diagnostic and treatment approach, patient education provided, and follow-up schedule. In dermatology, this often includes procedural documentation, detailed medication instructions, and lifestyle modifications.

Plan Section (P) Components

1. Diagnostic Procedures:

   • Biopsy type and technique (shave, punch, excisional, incisional)
   • Specimen handling and pathology orders
   • Laboratory studies ordered
   • Example: "Excisional biopsy with 2mm clinical margins, specimen to dermatopathology for H&E and immunohistochemistry as indicated"

2. Topical Medications:

   • Specific medication, strength, formulation (cream, ointment, solution, foam)
   • Application instructions (amount, frequency, duration, body areas)
   • Example: "Triamcinolone acetonide 0.1% ointment, apply thin layer to affected plaques on trunk and extremities twice daily for 2 weeks, then once daily for 2 weeks"

3. Systemic Medications:

   • Oral, injectable, or biologic therapies
   • Dosing schedule and monitoring requirements
   • Example: "Methotrexate 15mg PO weekly, with folic acid 1mg daily. Baseline labs (CBC, CMP, hepatitis panel) today, repeat CBC and CMP in 2 weeks"

4. Phototherapy:

   • Type (narrowband UVB, broadband UVB, PUVA)
   • Treatment schedule
   • Example: "Initiate narrowband UVB phototherapy, 3 times weekly, starting dose based on skin type"

5. Procedural Plan:

   • Specific procedures planned
   • Anesthesia, technique, wound care instructions
   • Example: "Cryotherapy to 6 actinic keratoses on bilateral forearms using liquid nitrogen spray technique, two freeze-thaw cycles"

6. Referrals:

   • Surgical oncology, plastic surgery, Mohs surgeon
   • Dermatopathology consultation
   • Other specialists as indicated
   • Example: "If melanoma confirmed, refer to surgical oncology for wide local excision and sentinel lymph node biopsy evaluation"

7. Patient Education:

   • Disease information
   • Medication application techniques
   • Sun protection counseling
   • Skin self-examination instructions
   • Example: "Educated patient on ABCDE criteria for monthly skin self-examination. Counseled on sun protection including daily SPF 30+, protective clothing, and sun avoidance during peak hours"

8. Follow-Up:

   • Timing of next appointment
   • Biopsy result communication plan
   • Monitoring schedule
   • Example: "Return in 7-10 days for suture removal and pathology review. Nurse will call with results if available sooner. If melanoma confirmed, urgent appointment for treatment planning"

Treatment Modality Categories in Dermatology

Topical Therapies:

• Corticosteroids (low, medium, high, super-potent)
• Calcineurin inhibitors
• Retinoids
• Antimicrobials
• Antifungals
• Immunomodulators

Procedural Therapies:

• Biopsies (shave, punch, excisional, incisional)
• Cryotherapy
• Electrodesiccation and curettage
• Excisions
• Mohs micrographic surgery
• Laser therapy
• Photodynamic therapy

Phototherapy:

• Narrowband UVB
• Broadband UVB
• PUVA
• Excimer laser

Systemic Therapies:

• Oral retinoids
• Immunosuppressants
• Biologics
• Oral antibiotics
• Antifungals
• Antivirals

Example of a Plan Section for Dermatology

AI-Assisted Documentation for Dermatology

AI-powered documentation tools are transforming dermatology practice, with 66% of healthcare providers now using AI in clinical settings. However, dermatology presents unique challenges and opportunities for AI-assisted documentation.

Benefits of AI Documentation in Dermatology

• Standardized terminology: AI can ensure consistent use of dermatological vocabulary
• Comprehensive lesion documentation: Prompts for complete lesion characterization
• Efficiency gains: Reduced documentation time by up to 50-75%
• Template integration: Automatic population of ABCDE criteria, BSA calculations

Dermatology-Specific AI Challenges

Image Integration Challenges:

• Most AI scribes cannot directly interpret clinical photographs
• Dermoscopic findings require verbal dictation for accurate capture
• Photography documentation (number of images, types) must be explicitly stated
• Image storage and EHR integration remain separate workflows

Lesion Description Accuracy:

• Complex morphological descriptions may require verification
• Multi-lesion documentation needs careful organization
• Laterality and anatomic location require explicit confirmation
• Size measurements should be stated clearly with units

What AI Captures Well in Dermatology:

• Patient history and symptom timeline
• Medication lists and allergy information
• Sun exposure and risk factor history
• Treatment plans and follow-up instructions
• Patient education discussions

What Requires Careful Review:

• Precise lesion measurements (verify exact numbers)
• Color descriptions (confirm accuracy)
• Anatomic locations (confirm laterality and specificity)
• ABCDE criteria assessments (verify each criterion)
• Dermoscopic findings (verify technical terminology)
• Procedure documentation (confirm technique details)

Tips for Using AI with Dermatology Documentation

1. State measurements explicitly: "The lesion measures nine millimeters by seven millimeters" rather than "about one centimeter"
2. Dictate colors precisely: "Dark brown with areas of blue-black pigmentation" rather than "dark colored"
3. Confirm anatomic locations: "Right upper back, inferior to the right scapula" rather than "upper back"
4. Verbalize dermoscopy findings systematically: "Dermoscopy shows irregular pigment network, blue-white veil centrally, and pseudopods at three o'clock and seven o'clock positions"
5. Review all objective findings carefully before signing AI-generated notes

AI and Photography in Dermatology

Current AI limitations with dermatology images:

• AI scribes typically cannot analyze clinical photographs
• Dermoscopic image interpretation requires specialized AI tools
• Photography documentation is workflow-adjacent, not integrated
• Verbal description remains essential for note accuracy

Best Practice: Dictate visual findings verbally while reviewing images, allowing AI to capture your clinical interpretation rather than relying on image analysis.

For more details, see our complete AI-Assisted Documentation Guide.

Telehealth Dermatology Documentation (Teledermatology)

Teledermatology has become an established practice modality, particularly for follow-up visits, medication management, and triage of new skin concerns. Per CMS 2026 guidelines, telehealth services continue to be covered with specific documentation requirements.

Teledermatology Modalities

Store-and-Forward (Asynchronous):

• Patient or referring provider submits photographs for review
• Dermatologist reviews images and provides consultation
• No real-time interaction required
• Documentation must note image quality and limitations

Live Interactive (Synchronous):

• Real-time video consultation
• Direct patient-provider interaction
• Immediate feedback and discussion
• Similar to in-person visit with visual limitations

Hybrid Models:

• Combination of submitted images and video consultation
• Often provides most comprehensive remote assessment

Photo Requirements for Teledermatology

Minimum Image Standards:

• Good lighting (natural light preferred, avoid shadows)
• In-focus images at appropriate distance
• Multiple views (overview and close-up)
• Reference for scale (ruler or coin if available)
• Consistent background (solid, non-distracting)

Required Images:

1. Overview image showing anatomic location
2. Close-up image of lesion with scale reference
3. Dermoscopic images when patient has dermatoscope or clinic-provided device

Telehealth-Specific Documentation Requirements

For virtual dermatology visits, document:

1. Visit Logistics:

   • Telehealth modality (store-and-forward vs. live video)
   • Platform used (HIPAA-compliant)
   • Patient and provider locations (state for licensure)
   • Consent for telehealth services

2. Image Quality Assessment:

   • Quality of photographs reviewed
   • Limitations due to image quality
   • Whether images were adequate for assessment

3. Modified Physical Examination:

   • What could be assessed via video/photographs
   • What could not be assessed remotely
   • Palpation limitations clearly documented

4. Telehealth Limitations Disclosure:

   • Clear statement of examination limitations
   • Recommendation for in-person follow-up if indicated
   • Conditions requiring in-person evaluation

Example Teledermatology Documentation - Store-and-Forward

Example Teledermatology Documentation - Live Video

For complete telehealth documentation guidance, see our Telehealth SOAP Notes Guide.

Free Dermatology SOAP Note Template

Speed up your documentation with our comprehensive dermatology SOAP note template. This template includes all essential elements for dermatological evaluations, lesion documentation, and treatment planning.

More Template Resources

• Free SOAP Note Templates - Download templates for all specialties
• Dermatology Examples - See more dermatology documentation examples
• SOAP Note Template Hub - Browse all available templates