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Templates, Clinical notes, Dermatology

Dermatology SOAP note template

A dermatology SOAP note template that sets out what belongs in each section, ready to adapt to your own clinic. Below it is the same note filled in by the wai scribe from an invented consultation, line by line, for the clinician to read and sign.

Updated . Written by our clinical team, generic by design, with no dosing advice.

01SOAP note

TemplateDermatology

Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]

Dermatology SOAP note

1Subjective

  • The reason for the visit, in the patient's own words where they are useful.
  • How long it has been going on.
  • When the lesion or rash appeared, and how it has changed in size, shape or colour.
  • Itch, bleeding or pain, and sun exposure history.
  • Relevant past medical and surgical history.
  • Current medicines, including anything bought over the counter.
  • Allergies and the reaction each one caused, or a record that none are known.

2Objective

  • Site, size, shape, colour and border of each lesion, with a body map reference.
  • Dermoscopy findings where used, and photographs taken with consent.

3Assessment

  • The working diagnosis and the differentials, including whether anything is suspicious.
  • Whether a biopsy or an urgent referral is needed.

4Plan

  • Investigations requested, and who will follow up the result.
  • Treatment agreed, as prescribed in the prescribing record.
  • Referrals made, and what was explained to the patient.
  • What should prompt the patient to get back in touch, and how.
  • When the next review is due.

Draft

[Clinician name]

[Role], [registration number]

Signed [date], [time]

How the wai scribe fills it

The same note, written from an invented consultation.

Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.

01SOAP note

SignedAI-assisted, edited by the clinician

Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person

Dermatology SOAP note

1Subjective

  • Mole on the back, darker over the last three months.00:30
  • Intermittent itch. Partner reports an increase in size. No bleeding.01:20

2Objective

  • Left upper back, 7 mm pigmented lesion, two colours, irregular border. Photographed with consent.03:40

3Assessment

  • Atypical pigmented lesion. Biopsy recommended to exclude melanoma.05:10

4Plan

  • Punch biopsy today. Histology result expected in two weeks, clinician to review.05:50
  • Advised to report any other changing lesion.06:30

Signed and filed

[Clinician name]

[Role], [registration number]

Signed [date], [time]

Questions

What goes in a dermatology SOAP note?

Subjective, Objective, Assessment and Plan. Each section on this page lists what belongs in it, written for dermatology.

Is the worked example a real patient?

No. The consultation is invented for this page, and no real patient or record is used.

Does the scribe sign the note?

No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.

Can we use our own note structure?

Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.

The SOAP note in other specialties

All clinical notes
  1. Private GPPrivate GP SOAP note
  2. AestheticsAesthetics SOAP note
  3. FertilityFertility SOAP note
  4. PhysiotherapyPhysiotherapy SOAP note
  5. Mental healthMental health SOAP note
  6. DentalDental SOAP note
  7. Longevity medicineLongevity medicine SOAP note

Further reading

  1. ProductThe AI medical scribe for clinics
  2. Read nextWho signs an AI clinical note, and how to review it
  3. Read nextSOAP and specialty note templates for an AI scribe
  4. RegulatorThe CQC compliance hub

Come back to the note, written and ready to sign.

See the wai scribe write a dermatology SOAP note on your own structure, in a 15 minute video call.

Request a demoEmail us