Dermatology SOAP Note Medical Transcription Samples

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient is an (XX)-year-old male who comes in for an annual skin exam. He has been treated for actinic keratosis in the past with liquid nitrogen. He was last seen 1 year ago and was seen in the interim for eczema. At that time, he was given triamcinolone ointment to use and encouraged to moisturize the area. Approximately 3 weeks ago, he saw his allergist who prescribed clobetasol cream to him to use for his eczema. The patient states that his eczema is intermittent and worse in the winter months. He has not noticed any new lesions.

OBJECTIVE:  This is a very pleasant (XX)-year-old Hispanic male. He is alert and oriented x3 and in no apparent distress. A full skin examination was carried out today including his face, head, neck, back, buttocks, abdomen, chest and bilateral upper and lower extremities. Distributed in his forehead are a few erythematous macules. His skin is somewhat dry and he has linear excoriation on his back, buttocks, and chest. His hands are dry and he has some hyperlinearity of his palms and fissuring of his fingertips. On his waistband is some erythema without scales; this is poorly demarcated. There are some overlying excoriations. Distributed on his back and chest are a few scattered, brown, stuck-on appearing papules without suspicious feature.

ASSESSMENT AND PLAN:
1.  Actinic keratosis on the forehead. After verbal informed consent was obtained, 3 lesions were treated with liquid nitrogen. Wound care discussed.
2.  Eczema. Given his history of environmental allergies and asthma, he will take Claritin 1 tablet q.a.m. and Atarax 10 mg 1 to 2 tablets at bedtime. He was instructed that Atarax may make him drowsy and to avoid driving while taking this medication. We encouraged him to moisturize with suitable cream daily after showering. He may use clobetasol ointment for 2 to 3 weeks when his eczema flares.
3.  Seborrheic keratosis, benign, reassured. He will follow up in 1 year or sooner p.r.n.

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DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  This (XX)-year-old gentleman returns for followup of psoriasis and also because of history of basal cell carcinoma. He feels the Dovonex cream and the fluocinonide ointment are still effective and he tends to alternate them. He has no other concerns regarding his skin today. Denies new or changing moles.

OBJECTIVE:  Alert and oriented x3. Normal mood. Normal body habitus. On examination of face, neck, chest, abdomen, back, upper and lower extremities, hands and feet bilaterally, there are bright pink 3-4 cm scaly plaques on the trunk, arms and legs. There is a shiny tan, 3 mm, slightly elevated papule at the left lower anterior neck. This is several centimeters anterior to the hyperpigmented scar from the basal cell carcinoma he had previously on his left neck, and on his right lateral cheek, there is a shiny, flesh-colored, 3 mm, dome-shaped papule.

ASSESSMENT:
1.  Plaque psoriasis.
2.  The lesion on the neck is a probable basal cell carcinoma and on his right lateral cheek either basal cell carcinoma or dermal nevus.

PLAN:  Discussed with the patient obtaining shave biopsy on the cheek and neck.

PROCEDURE:  Reviewed the risks of pain, bleeding, infection, expected scar from the procedure. He had the opportunity to ask questions. Written consent was obtained. Verified the patient’s identification. The patient verified the site of the procedure. Timeout protocol. Anesthesia, 0.5% lidocaine with epinephrine 0.5 mL to each of the two areas. Shave biopsy specimens obtained and sent for pathology. Electrodesiccation for hemostasis. Dressings applied. Followup is scheduled for 1 year.

More Derm SOAP Note Samples

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DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient is a (XX)-year-old man who comes in for his annual skin checkup. He has no specific skin complaint, just wishes a general skin examination because he has had multiple moles. He has had moles removed in the past, which revealed lentiginous compound nevi with mild atypia.

OBJECTIVE:  This is a well-appearing (XX)-year-old Hispanic male in no acute distress. He is alert and oriented x3 and pleasant. His mood, affect and grooming seem normal. A full skin exam was carried out including the face, scalp, head, neck, back, buttocks, chest, abdomen and bilateral upper and lower extremities. Scattered on his back and chest are numerous 6 mm to 1 cm, well-demarcated, symmetric, tannish-reddish papules without suspicious features. Scattered on his abdomen and bilateral upper and lower extremities are multiple 4-10 mm well-demarcated, uniformly-colored, brown macules without suspicious features. There are also multiple scars from removal of nevi.

ASSESSMENT AND PLAN:  Numerous large benign-appearing nevi on the trunk and extremities. Some of them are atypical appearing in size. We reviewed the ABCDs of melanoma and encouraged him to perform monthly self-skin exams. Advised him to wear sunscreen with at least an SPF of 30 when going out. He will follow up in 1 year or sooner p.r.n.


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