Free Dermatology SOAP Note Templates (Ready to Use in 2026)

Looking for a SOAP note template for dermatologists you can use today?

Dermatology SOAP templates help providers document skin concerns, exam findings, diagnosis, treatment plans, and follow-up instructions in a structured format.

For dermatology practices, this matters because every note needs more than a simple “rash improved” or “lesion checked.”

A Dermatology note should document what the patient says, what the provider observes, the location of the skin problem, the changes to the skin problem, treatment that will be provided, and what the patient should do next.

These dermatology documentation templates are designed for dermatologists, dermatology PAs, nurse practitioners, med spas with clinical documentation needs, and specialty practices seeking faster, more consistent notes.

This guide provides complimentary, downloadable dermatology SOAP note templates for general dermatology visits, acne follow up visits and suspicious lesion / skin check documentation. These templates are created for dermatologists, dermatology PAs, NPs, and specialty practices who wish to have quicker, cleaner and more consistent charting. 

Download Includes:

General dermatology SOAP note template

Acne follow-up SOAP note template

Suspicious lesion/skin check SOAP note template

What Is a Dermatology SOAP Note?

A dermatology SOAP note is a structured clinical note used to document a skin-related patient visit. SOAP stands for Subjective, Objective, Assessment, and Plan.

SOAP stands for:

SOAP Section	What It Means	Dermatology Example
Subjective	What the patient reports	Itching, rash duration, acne flare, changing mole, medication use
Objective	What the provider observes	Lesion size, color, location, scaling, redness, distribution
Assessment	Diagnosis or clinical impression	Acne vulgaris, dermatitis, psoriasis, suspicious lesion
Plan	Treatment and next steps	Medication, biopsy, skin care advice, follow-up, referral

In simple terms, a dermatology note should make the visit easy to understand later.

Another clinician should be able to open the note and quickly understand:

• Why the patient came in
• What was examined
• What was found
• What diagnosis or concern was documented
• What treatment or next step was recommended
• When should the patient follow up

The goal is not to create longer notes.

Who Can Use These Dermatology Assessment Notes?

These templates are useful for:

• Dermatologists
• Dermatology physician assistants
• Dermatology nurse practitioners
• Private dermatology clinics
• Multi-provider specialty practices
• Med spas with clinical documentation workflows
• Practices moving from paper notes or Word templates into an EHR

They can also assist practices in creating a library of dermatitis charting templates prior to transferring it to a dedicated dermatology EHR.

Why Do Dermatology SOAP Notes Matter?

Dermatology practices often manage high patient volume.

In one day, you can have acne appointments, eczema appointments, psoriasis appointments, mole check, biopsy consultations, checking on medications, cosmetic consultations, teledermatology consultations, and follow-up appointments for procedures.

That creates a real documentation challenge. Providers need to chart quickly, but the note still needs enough detail to support clinical care, billing review, follow-up, and patient safety.

The most common dermatology documentation gaps include:

• Missing lesion location
• No lesion size or measurement
• Vague skin exam findings
• No note on whether the lesion changed
• No treatment response history
• No patient education documented
• No follow-up interval
• Procedure details missing from the plan
• Copy-paste notes that do not reflect the current visit

These gaps can slow down care. They can also create extra work for billing teams, front office staff, and providers who need to review the chart later.

A strong SOAP note helps solve this by giving providers a consistent structure without forcing them to write from scratch every time.

Related: 5 Easy Steps to Create Customized SOAP Notes within Vozo EHR (Step-by-Step)

Dermatology SOAP Note Checklist

Documentation Area	What to Capture
Chief complaint	Main reason for the visit
History	Duration, symptoms, triggers, prior treatment
Skin exam	Location, size, lesion type, color, border, distribution
Assessment	Diagnosis, severity, status, differential if needed
Plan	Treatment, procedure, education, follow-up
Safety details	Return precautions, warning signs, and biopsy follow-up if relevant

What Should Be Included in a Dermatology Clinical Note?

A useful dermatology encounter note should include the basic SOAP structure, but with dermatology-specific details.

1. Chief Complaint

Start with the main reason for the visit.

• Acne follow-up
• Rash on arms
• Changing mole on the back
• Annual skin check
• Itchy scalp
• Medication follow-up
• Biopsy site check

2. History of Present Illness

Capture the story behind the skin concern.

• When it started
• Location
• Symptoms
• Severity
• Triggers
• Prior treatment
• Medication response
• Whether it is improving, worsening, or stable

3. Skin Exam Findings

This is one of the most important parts of a dermatology note.

• Location
• Lesion type
• Size
• Number of lesions
• Color
• Border
• Shape
• Distribution
• Scaling
• Crusting
• Bleeding
• Drainage
• Tenderness
• Dermoscopy or photo documentation, if used

4. Assessment

Document the diagnosis or clinical impression.

• Acne vulgaris, mild inflammatory type
• Atopic dermatitis flare
• Psoriasis, stable
• Neoplasm of uncertain behavior
• Benign-appearing nevus
• Seborrheic keratosis
• Actinic keratosis

5. Plan

The plan should explain what happens next.

• Medication plan
• Procedure plan
• Biopsy plan, if needed
• Patient education
• Skin care instructions
• Sun protection counseling
• Wound care instructions
• Follow-up timeline
• Return precautions

Related: 5 Powerful Features Your Dermatology EHR Needs

Dermatology SOAP Note Template 1: Acne Follow-Up

Acne is one of the most common types of dermatology visits. An effective SOAP note for acne will state more than just the presence of acne. It should record the type of acne, what has worked well in treating it, the tolerance of treatment, the presence or absence of scarring and/or pigmentation.

This is particularly beneficial for follow-up visits as the treatment may take a few weeks and providers need to be able to make comparisons between visits.

The dermatology clinical note examples can assist providers in developing a more standardized and clean clinical note for subsequent visits.

Dermatology SOAP Note Template 2: Suspicious Lesion / Skin Check

Suspected lesions and skin inspections should be thoroughly documented.

These visits can cause difficulties when the words are not precise. There should be a note that clearly describes the lesion, the location, if the lesion has changed or not, and the provider’s next action.

This template is used for mole checks, change of spots, non-healing lesions, bleeding lesions, or targeted skin checks.

Dermatology SOAP Note Example

Here is a simple completed example for an acne follow-up visit.

Example: Acne Follow-Up SOAP Note

Chief Complaint: Acne follow-up

Subjective

Patient comes in with a follow-up for facial acne. Reduced the number of acne lesions from the previous visit, but still has inflammatory acne lesions on the chin and cheeks. Denies severe irritation. Reports consistent use of the current skin care routine. No new medication allergies reported.

Objective

Scattered closed comedones and a few inflammatory papules were noted on the bilateral cheeks and chin. Mild post-inflammatory erythema is present. No nodulocystic lesions noted. No signs of secondary infection.

Assessment

Acne vulgaris, mild to moderate inflammatory and comedonal pattern, improving but not fully controlled.

Plan

Reviewed treatment response and current skin care routine. Discussed continued use of gentle cleanser, non-comedogenic moisturizer, and sunscreen. Treatment plan adjusted per provider judgment. Follow-up in 8–12 weeks or sooner for worsening symptoms or medication intolerance.

Free Dermatology SOAP Templates vs EHR Templates

Free SOAP note templates are a good starting point. They help providers stop writing every note from scratch. They also help practices standardize common documentation patterns across providers.

But downloadable templates have limits.

They usually sit in a PDF, Word document, or Google Doc. That means providers still need to copy, paste, edit, and manually connect the note to the patient record.

Free templates work well when you need to:

• Create a basic note structure
• Train new staff
• Standardize documentation
• Improve note consistency
• Build a starter template library
• Reduce blank-page charting

An EHR works better when you need to:

• Use templates inside the patient chart
• Connect notes with scheduling
• Document telehealth visits
• Manage eRx workflows
• Connect billing to the encounter
• Track follow-ups
• Use specialty-specific templates
• Reduce copy-paste work
• Keep intake, notes, billing, and patient communication in one place.

A free template helps you write the note. A dermatology-ready EHR helps your practice manage the workflow around the note. 

For growing practices, dermatology EHR templates can reduce manual copying and keep documentation connected with clinical, billing, and patient communication workflows.

How to Customize Dermatology SOAP Note Templates

The best SOAP note template is not the longest one. It is the one your providers will actually use. To keep your dermatology notes useful, customize templates by visit type.

For acne visits, include:

• Acne type
• Severity
• Location
• Treatment response
• Medication tolerance
• Scarring or pigmentation
• Skin care routine
• Follow-up interval

For lesion checks, include:

• Exact location
• Size
• Color
• Border
• Surface
• Change history
• Dermoscopy or photo use
• Biopsy decision
• Follow-up plan

For general dermatology visits, include:

• Chief complaint
• Symptom history
• Exam findings
• Diagnosis
• Treatment plan
• Patient education
• Return precautions

Avoid building one massive dermatology template for every visit. That usually slows providers down. Instead, create a short general template and a few condition-specific templates for the most common visits.

5 Common Dermatology Note Mistakes to Avoid

1. Writing vague skin exam findings – “Rash present” or “lesion noted” is usually not enough. Better notes describe location, appearance, size, color, distribution, and symptoms when relevant.

2. Missing treatment response – For acne, eczema, psoriasis, and chronic conditions, the note should show whether treatment is working. This helps the provider make better follow-up decisions.

3. Forgetting follow-up instructions – Dermatology notes should clearly state when the patient should return and what warning signs should prompt an earlier visit.

4. Copying the same note forward – Templates save time, but copied notes can create confusion if they are not updated. Each note should reflect the current visit.

5. Keeping templates outside the workflow – There is a downloadable template, but it still needs to be done manually. With templates integrated into an EHR, such as Vozo, providers can document more quickly, and link the note to scheduling, telehealth, prescriptions, billing, and patient communication.

Move Your Dermatology Templates Into Vozo EHR

Free SOAP templates are useful when you need a starting point. As your practice expands, however, static templates can lead to additional copy/paste activity.

Vozo EHR allows dermatology practices to handle personalized notes, specialty templates, patient intake, telehealth, eRx, billing, patient communication and follow-ups in one connected EHR workflow.

Your team can work directly within the patient chart to keep templates rather than in a separate document.

Vozo can transform a dermatology documentation template into a connected template, that enables dermatology practices to handle clinical workflows throughout the day.

Frequently Asked Questions

1. What is included in a dermatology SOAP note?

A dermatology SOAP note has sections of subjective, objective, assessment, and plan. It should include patient’s symptoms, skin exam findings, diagnosis or clinical impression, treatment plan, patient education, and follow-up instructions. It should also contain details of the location, description, size, distribution, and the procedure if applicable of the lesions in dermatology practice.

2. Are these dermatology note templates free?

Yes. These dermatology note templates are designed as free downloadable templates that practices can use as a starting point for common dermatology visits, including acne, eczema, psoriasis, lesion checks, skin exams, procedure follow-ups, and teledermatology visits.

3. Can dermatology SOAP note templates be used in an EHR?

Yes. A dermatology clinical note can be adapted for use inside an EHR. In Vozo, practices can use customizable notes, intake forms, templates, scheduling, telehealth, eRx, billing, and task workflows to keep documentation connected to daily clinic operations.

4. What is the best dermatology SOAP note template?

The best dermatology documentation is specific to the visit type. Acne, eczema, psoriasis, lesion checks, full-body skin exams, and procedure follow-ups all need different documentation prompts. A good template should be fast to complete, clinically clear, and easy to customize.

5. Why should dermatology practices use SOAP note templates?

Dermatology practices use SOAP note templates to reduce repetitive typing, improve documentation consistency, support follow-up care, standardize provider workflows, and reduce missing details. Templates are especially useful for high-volume practices where providers document many similar visit types each day.

6. Do SOAP note templates help with dermatology billing?

SOAP note templates can help billing teams by making documentation easier to review. They can prompt providers to include diagnosis, lesion details, procedure information, medical decision-making, and follow-up plans. However, coding and billing should always follow current payer, CPT, ICD-10, and compliance requirements.

7. Can I use these templates for teledermatology visits?

Yes. The teledermatology SOAP note template includes fields for visit type, patient location, consent, image quality, limitations of virtual assessment, clinical findings, and follow-up instructions. This helps document the unique details of a virtual dermatology encounter.