SOAP Note Example
Dermatology SOAP Note Example
Below is a complete SOAP note example for a dermatology visit evaluating a suspicious pigmented lesion on an adult patient. This example demonstrates proper documentation of lesion morphology using standardized dermatologic terminology, ABCDE criteria assessment, dermoscopic findings, shave biopsy procedural documentation, and pathology follow-up planning.
Complete Dermatology Note
SUBJECTIVE:
Patient is a 47-year-old male presenting for evaluation of a pigmented lesion on his upper back that his wife noticed has changed over the past 3-4 months. Patient reports the lesion has become darker and appears larger than he remembers, though he cannot see it directly and relies on his wife's observations. Denies any associated symptoms — no pain, pruritus, bleeding, crusting, or ulceration. Denies any recent trauma to the area. Patient reports having multiple moles since childhood but states this particular lesion has shown noticeable change. Has never had a full-body skin examination by a dermatologist. No personal history of skin cancer, atypical moles, or dysplastic nevus syndrome. Family history: father diagnosed with melanoma in situ on the forearm at age 62 (treated with wide local excision, no recurrence). No other family history of skin cancer. Sun exposure history: significant recreational sun exposure throughout his 20s and 30s including outdoor sports and infrequent use of sunscreen; reports 3-4 blistering sunburns during adolescence. Fitzpatrick skin type II (fair skin, light brown hair, blue eyes, burns easily, tans minimally). No indoor tanning bed use. Occupation: software engineer (primarily indoor work). Current skin care: recently started using SPF 30 sunscreen on exposed areas after his father's melanoma diagnosis. No current medications. No known drug allergies.
OBJECTIVE:
Full-body skin examination performed with the patient in a gown. Index lesion located on the right upper back, approximately 4 cm inferior to the right scapular spine and 6 cm lateral to the midline. Gross morphology: irregularly shaped pigmented macule-to-thin-papule, measuring 8 mm x 6 mm (long axis oriented superomedially to inferolaterally). Color: variegated — predominantly medium brown with areas of dark brown to black at the superomedial border and a 2 mm focus of blue-gray pigmentation at the inferior aspect; a small area of tan-pink depigmentation (possible regression) noted centrally. Borders: irregular and poorly defined with angular notching at the 2 o'clock and 7 o'clock positions; lateral margins fade indistinctly into surrounding skin. Surface: smooth with a subtle palpable component at the dark superomedial portion; no ulceration, erosion, crusting, or bleeding. No satellite lesions. Surrounding skin: mild solar elastosis and scattered lentigines across the upper back and shoulders. ABCDE assessment: Asymmetry — positive (lesion is asymmetric in both axes for shape and color distribution); Border — positive (irregular, notched, and indistinct margins); Color — positive (4 colors identified: tan, medium brown, dark brown/black, and blue-gray); Diameter — positive (8 mm, exceeds the 6 mm threshold); Evolution — positive (reported change in color and size over 3-4 months per patient/spouse history). Dermoscopy (polarized, non-contact): atypical pigment network with broadened, irregularly thickened, and variably spaced dark brown lines predominantly in the superomedial half; 2 mm structureless blue-gray area at the inferior pole (consistent with regression or deep melanin deposition); irregular globules at the periphery in a non-uniform distribution; focal areas of regression (white scar-like depigmentation with peppering centrally); no definitive ulceration or milky-red areas. Dermoscopic assessment: multicomponent pattern with features concerning for melanoma — 3-point checklist score: asymmetry of structures (1 point), atypical network (1 point), blue-white structures (1 point) — total 3/3 (positive, biopsy indicated). Remainder of full-body skin examination: approximately 40-50 melanocytic nevi across the trunk and extremities, most appearing clinically benign (symmetric, uniform color, regular borders, <6 mm). Two additional nevi flagged for clinical monitoring — a 5 mm mildly atypical-appearing nevus on the left anterior chest (slightly irregular border, uniform medium brown color, no dermoscopic atypia) and a 4 mm nevus on the right lateral calf (symmetric but darker than surrounding nevi). Baseline clinical photographs taken of these two monitored nevi. No other suspicious lesions identified. Procedure performed: shave biopsy of the right upper back lesion. Informed consent obtained including discussion of risks (bleeding, infection, scarring, incomplete sampling, need for re-excision), benefits (histopathologic diagnosis), and alternatives (punch biopsy, excisional biopsy, monitoring). The lesion was biopsied via saucerized (deep shave) technique to obtain adequate depth for Breslow thickness measurement if melanoma is diagnosed. Procedure: area prepped with chlorhexidine; local anesthesia with 1% lidocaine with epinephrine 1:100,000 (2 mL injected circumferentially around and beneath the lesion); saucerized shave biopsy performed using a DermaBlade, extending 1-2 mm beyond the visible clinical margins laterally and to the deep reticular dermis in depth; specimen measured 12 mm x 10 mm, placed in 10% formalin, labeled with patient name, DOB, anatomic site (right upper back), and submitted to Dermpath Associates for histopathologic evaluation with the clinical note: 'Rule out melanoma — atypical pigmented lesion with dermoscopic atypia, multicomponent pattern, blue-white structures, atypical network.' Hemostasis achieved with aluminum chloride 20% solution. Wound dressed with petrolatum and adhesive bandage. No immediate complications.
ASSESSMENT:
Clinically atypical melanocytic lesion of the right upper back with multiple features concerning for melanoma: ABCDE criteria all positive, dermoscopic multicomponent pattern with atypical network, blue-white structures, irregular peripheral globules, and regression features (3-point checklist score 3/3). The patient has significant risk factors for melanoma including Fitzpatrick type II skin, history of blistering sunburns in adolescence, extensive cumulative UV exposure, first-degree family history of melanoma, and age greater than 40. The constellation of clinical, dermoscopic, and risk factor findings places this lesion at high clinical suspicion for melanoma. The differential diagnosis includes melanoma (in situ or invasive), severely dysplastic nevus (high-grade dysplastic nevus with architectural disorder and cytologic atypia), melanocytic nevus with regression, and less likely a pigmented actinic keratosis or pigmented basal cell carcinoma, though the dermoscopic pattern is most consistent with a melanocytic neoplasm. Definitive diagnosis requires histopathologic evaluation. The two additional nevi flagged during the full-body exam are low concern currently but warrant serial clinical and photographic monitoring given the patient's overall risk profile.
PLAN:
Biopsy wound care instructions provided: apply petrolatum (Vaseline or Aquaphor) to the wound twice daily and cover with a clean adhesive bandage until fully re-epithelialized (typically 10-14 days); keep the wound moist — do not allow a dry scab to form; clean gently with soap and water daily; avoid submerging in pools, hot tubs, or baths until healed; no heavy lifting or activities that stretch the upper back skin for 5-7 days to minimize wound dehiscence. Signs of infection requiring prompt contact: increasing redness, warmth, swelling, purulent drainage, or fever. Pathology results expected within 7-10 business days. Patient will be contacted by phone by the provider as soon as the pathology report is available. If melanoma is confirmed: patient will be scheduled urgently for wide local excision — surgical margins will be determined by Breslow thickness per NCCN guidelines (melanoma in situ: 0.5-1.0 cm margins; invasive melanoma ≤1.0 mm: 1 cm margins; 1.01-2.0 mm: 1-2 cm margins). Sentinel lymph node biopsy will be discussed if Breslow thickness exceeds 0.8 mm or if ulceration or high mitotic rate is present on histopathology. If severe dysplasia or melanoma in situ with positive histologic margins: re-excision with appropriate margins. If benign or mildly dysplastic nevus with clear margins: return to routine monitoring schedule. Full-body skin examination to be performed annually given the patient's melanoma risk factor profile (family history, UV exposure history, Fitzpatrick type II, high total nevus count). Monitored nevi (left anterior chest, right lateral calf): clinical and photographic comparison at the next annual exam — biopsy if any change is noted in size, shape, color, or dermoscopic pattern. Patient counseled on sun-protective behaviors: daily broad-spectrum SPF 30 or higher sunscreen to all exposed skin (reapply every 2 hours with outdoor activity), protective clothing (UPF-rated shirts, wide-brimmed hats), seek shade between 10 AM and 4 PM, avoid intentional tanning, and perform monthly skin self-examinations with spouse assistance for areas that cannot be directly visualized. Patient verbalized understanding of all instructions. Next appointment: pending pathology results — patient to expect a phone call within 10 business days.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
Dermatology subjective documentation must capture the timeline and nature of any lesion changes reported by the patient or an observer, as well as associated symptoms such as pain, itching, bleeding, or ulceration — and equally important, the absence of these symptoms. Document a thorough melanoma risk factor profile: personal and family history of skin cancer (with specific type, location, and treatment), Fitzpatrick skin type, sun exposure history including blistering sunburns (especially in childhood and adolescence), tanning bed use, and total nevus count impression. This risk factor documentation directly influences the clinical suspicion level, the decision to biopsy, and the recommended surveillance interval, and it provides the medical rationale that justifies the treatment plan.
Objective
The dermatology objective section demands precise morphologic description using standardized terminology: lesion type (macule, papule, plaque, nodule), exact measurements in millimeters, anatomic location with reference landmarks, color characterization (use specific descriptors — variegated, blue-gray, tan-pink — not just 'brown'), border description, and surface features. Document the ABCDE criteria individually and state whether each is positive or negative. Dermoscopy findings should describe specific structures (pigment network character, globules, regression structures, blue-white structures, vascular patterns) and include a structured scoring system such as the 3-point checklist or 7-point checklist. Biopsy procedural documentation must include consent, technique and rationale for technique choice, specimen dimensions, depth achieved, labeling, and the specific clinical question communicated to the pathologist.
Assessment
The dermatology assessment should state the level of clinical suspicion, synthesize the clinical and dermoscopic findings that support that suspicion, and enumerate the risk factors that elevate the patient's baseline melanoma probability. Present a rank-ordered differential diagnosis with the most concerning diagnosis listed first. Explain why histopathologic evaluation is the definitive next step — clinical and dermoscopic examination alone cannot distinguish a severely dysplastic nevus from early melanoma. Acknowledge additional lesions identified during the full-body exam and provide your clinical assessment of their current risk level. This section demonstrates that the biopsy decision was clinically justified and not reflexive.
Plan
The dermatology plan must include detailed wound care instructions written for the patient (moist healing, no dry scab, signs of infection), the expected turnaround time for pathology results, and a clear decision tree for next steps based on the possible pathology outcomes — this contingency planning demonstrates proactive clinical thinking and prepares the patient for potential surgical follow-up. Reference specific guideline-based excision margins (NCCN) and the criteria for sentinel lymph node biopsy so the documented plan is defensible and transparent. Include the recommended surveillance schedule for the full-body exam and monitored nevi, and document the sun-protective counseling provided. The plan should read as a complete roadmap that any provider could follow regardless of the pathology result.
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