General Dermatology SOAP Note Example

Subjective Assessment:

{age} years old {female/male} patient with a history of {enter the condition here}.

The patient complained about the following skin condition {rash/lesion} on {date} at {time}.

The {rash/lesion} is {itchy/painful/asymptomatic}.

Is {rash/lesion} spreading? - {yes/no}.

Provoking factors present: {Season/ Temperature change/ Exercise/ Medication/ Allergens/ Immune system disorder/ None}.

Melanoma ACBCDE criteria: {Asymmetry/ Border/ Color/ Diameter/ Evolving/ No symptoms present}.

Stevens-Johnson syndrome: {Top layer of skin slips, leaving a pink and moist skin indicating positive Nikolsky’s sign/Mucosal and painful rash present/Painful rash that spreads and blister follows/None detected}

Necrotizing fasciitis: {Pain significantly more than the wound’s appearance/None}

Past Medical History: {Diabetes/Atopy/Psoriasis/Skin cancer/STD/Shingles/HIV/Blood Transfusion/None}

Family Medical History: {No relevant history/Genetic conditions/Atpoy/Psoriasis/Melanoma}

Personal and SocHx: {Tobacco use/Recreational drug use/EtOH exposure/Sun exposure/Alcohol consumption/Poor diet/Lack physical activity/None}

Medicines: {Use of [medicine] for [existing] skin conditions/No relevant medications}

Objective Assessment

Size: {add size here}, surface area: {add surface area} Color: {erythematous/purpora/hyperpigmentation/vitiligo/hypopigmentation}

Rash symmetry: {linear/ring/wavy/clustered/discoid/recticular/target}

Rash Dermatology SOAP Note

Age: {add age here} History of present illness (HPI):

1. The rash was discovered on {date}.
2. The rash was first discovered on {location}.
3. Rash feels: {itchy/burns/hurts}.
4. Previous treatments (if any): {grams} dose of {medicine} taken {list frequency of medication}.
5. The rash has {spread/stayed the same} over time.

Patient contacts {are none/are} with {farm animals/ house pets/ public transportation/ hotel stay}.

PmHx: {Diabetes/Atopy/Psoriasis/Skin cancer/STD/Shingles/HIV/Blood Transfusion/None}

Allergies: {No allergies/Allergic to [something], reaction is [reaction]}.

Consuming medications: {Use of [medicine] for [existing conditions]/No relevant medications}

FamHx: {No relevant history/Genetic conditions/Atpoy/Psoriasis/Melanoma}

Objective: Location: {hands/ legs/ abdomen/lower back} Surface: {cracked/ smooth/ rough/ scales}

Rash type: {purpuric/ nodular/ crusting/ papular/ erythematous/ bullous/ tender/ raised/ macular/ maculopapular/ flaking/ excoriated/ urticarial/ pustular/ vesicular}

Rash shape: {no shape/pedunculated/oval/rounded}

Rash color: {rose/ red/ purple/ brown/ white/ pink}

Rash is {single/mutliple}: {discrete/annular/linear/multiple/generalized}

Dermatology SOAP Note Template

Subjective

Patient is {age} year old {male/female} who visited {reason for visit}.

PmHx: {Diabetes/Atopy/Psoriasis/Skin cancer/STD/Shingles/HIV/Blood Transfusion/None}

Family history: {No relevant history/Genetic conditions/Atpoy/Psoriasis/Melanoma}

Objective

Physical examination notes: {add your physical examination notes here}.

Assessment and Plan

• {condition 1}: On {locations e.g. abdomen}, patient has {papules/nodules/etc}. We discussed the treatment of choice {add your treatment of choice and details of medication}.
• {condition 2}: On {locations e.g. forehead}, patient has {papules/nodules/etc}. We discussed the treatment of choice {add your treatment of choice}.
• {condition 3}: On {locations e.g. abdomen}, patient has {papules/nodules/etc}. We discussed the treatment of choice {add your treatment of choice}.

Followup of the patient is scheduled in {x} {days/weeks/months/year}.

Short Skin Rash Dermatology SOAP Note Example

Skin rash: {age} years old {female/male} patient has {localized/generalized} rash.

Rash is {purpuric/ nodular/ crusting/ papular/ erythematous/ bullous/ tender/ raised/ macular/ maculopapular/ flaking/ excoriated/ urticarial/ pustular/ vesicular}.

Blood drainage: {no drainage}/{purulent blood drainage/ serous blood drainage/ sanguineous blood drainage}