SOAP Note Template (Dermatology)
Published: 10/22/2025
About this template:
This dermatology SOAP note template provides structured documentation for skin, hair, and nail conditions. It includes sections for detailed lesion descriptions, dermatological examination findings, diagnostic procedures, and treatment plans. The template facilitates clear documentation of both medical and cosmetic dermatology visits, ensuring thorough records for follow-up care and treatment monitoring.
Preview template
Subjective: 45-year-old female presents with a 3-month history of an enlarging lesion on her right upper back. Reports the spot has changed in color from light brown to darker brown with irregular borders. No bleeding, itching, or pain. Patient has a history of significant sun exposure in her 20s with several blistering sunburns. No personal or family history of skin cancer. Concerned about melanoma risk.
Objective: Dermoscopic examination reveals a 7mm asymmetric pigmented lesion on the right scapular region with irregular borders and variegated coloration (brown, dark brown, and black). Exhibits characteristics concerning for melanoma including asymmetry, border irregularity, and color variation. Remainder of full-body skin examination reveals multiple benign-appearing nevi and mild actinic damage on sun-exposed areas. No palpable lymphadenopathy.
Assessment and Plan:
- Atypical pigmented lesion, suspicious for melanoma
- Excisional biopsy with 2mm margins performed today, specimen sent to pathology
- Full-body photography completed for future comparison
- Await pathology results to determine further management (may require wider excision and sentinel lymph node biopsy depending on depth if melanoma confirmed)
Patient Education:
- Discussed biopsy procedure, wound care instructions, and when to expect results (7-10 days)
- Reviewed signs of infection and importance of keeping wound clean and dry
- Educated on ABCDE criteria for monitoring moles and importance of monthly self-examinations
- Strongly advised daily broad-spectrum SPF 30+ sunscreen, protective clothing, and sun avoidance during peak hours
Follow-up appointment scheduled in 2 weeks to review pathology results and discuss treatment plan. Patient instructed to call sooner if wound concerns arise.
