A dermatology note precise enough that someone who hasn't seen the rash can picture it: primary lesion, size, color, arrangement and distribution.
By Francisco Sanchez, BSN, RN · ER nurse and FNP student · Updated October 2026
Setting: Outpatient dermatology or primary care visitPatient: Fictional patient: 35-year-old man
SSubjective
Chief complaint
"Itchy rash on my arms after hiking."
HPI
Hiked through coastal brush 3 days ago without washing his skin or clothes until that evening. The rash started 2 days later on the right forearm and spread to both forearms and the left wrist. Intense itch, no pain, some clear blisters. No fever. No new soaps, detergents or medications. Tried hydrocortisone 1% cream twice daily for 2 days with little relief; diphenhydramine at night helps him sleep. No face, eye or genital involvement; no trouble breathing or swallowing.
History
Similar rash as a teenager after camping. No eczema, asthma or allergies.
Medications
None besides those above.
OObjective
Morphology
Multiple erythematous papules and vesicles, 2-5 mm, some coalescing into edematous plaques, several in linear streaks. A few excoriations with serous crust. No pustules, honey-colored crust or purulent drainage.
Distribution
Dorsal and volar forearms bilaterally and the left wrist; asymmetric; about 4% of body surface area.
Other
Face, eyelids, genitals and mucosa spared. Scalp and nails normal. No streaking redness. Vital signs normal.
AAssessment
Diagnosis
Acute allergic contact dermatitis to urushiol (poison oak), localized: linear vesicles on exposed skin 2-3 days after brush exposure, with a prior similar reaction.
Differential
Irritant contact dermatitis (no irritant exposure; linear pattern favors a plant). Herpes zoster (bilateral, not dermatomal, itchy rather than painful). Secondary bacterial infection (no honey crust or pus). Scabies (no burrows, spares web spaces).
PPlan
Treatment
Clobetasol 0.05% cream to the affected forearm and wrist areas twice daily for up to 14 days; not on the face, groin or underarms. Cool compresses 15-20 minutes several times a day; calamine as needed. Diphenhydramine 25 mg at night as needed for itch-related sleep loss (causes drowsiness). Oral steroids not needed for localized disease; if it spreads widely or reaches the face or genitals, use a prednisone taper over 2-3 weeks (shorter courses can rebound).
Education
Wash skin, clothing, gear and any pet that touched the plant; blister fluid does not spread the rash. Learn to recognize poison oak; long sleeves and a barrier cream before hikes.
Follow-up
As needed. Return for spreading redness, pus or fever, involvement of the face, eyes or genitals, or no improvement in 1 week.
Fictional patient, written for learning. Follow your program's and facility's documentation standards.
Why this note works
The morphology names the primary lesion, size, color, arrangement and secondary changes.
Distribution and estimated body surface area guide how strong the treatment needs to be.
Treatments already tried, and how well they worked, are documented.
The plan specifies agent, strength, where, how often and how long, plus when to escalate.
What students often miss
Treatments tried and the response
Distribution and pattern
Mucosal, nail and scalp involvement
Dermatology SOAP note template
Describe it so precisely that someone who hasn't seen it could picture it.
SSubjective
Chief complaint
HPI
Onset, location where it started, evolution, itch/pain, triggers, exposures, treatments tried and response.
Reading examples helps. Writing your own note and seeing exactly what you missed is what makes you better. SOAPy gives you a realistic case and checks your note section by section.