Dermatology SOAP Notes: Complete Guide 2026
Master dermatology documentation with comprehensive templates, ABCDE melanoma criteria, lesion terminology, dermoscopy findings, procedure documentation, and clinical examples for skin cancer and common conditions.
6 Full Examples
Acne, Psoriasis, Melanoma, BCC
Dermatology SOAP Note Structure
Each section captures specific dermatologic information essential for diagnosis and treatment
Subjective
Patient-reported skin concerns, symptom timeline, and dermatologic history
Key Elements:
- Chief complaint (lesion location, appearance, symptoms)
- Onset and duration of skin condition
- Symptom timeline (stable, growing, changing)
- Associated symptoms (itching, pain, bleeding, discharge)
- Previous treatments attempted and results
- Personal history of skin cancer or conditions
- Family history of skin cancer or genetic conditions
- Sun exposure history and tanning bed use
- Occupational exposures
- Current skincare regimen and allergies
Sample Phrases:
Objective
Physical examination findings, lesion characteristics, and dermoscopy results
Key Elements:
- Lesion location (anatomic site, body diagram)
- Size in millimeters (length x width)
- Primary morphology (macule, papule, plaque, etc.)
- Color and pigmentation patterns
- Border characteristics (well-defined, irregular)
- Surface texture (smooth, scaly, crusted)
- ABCDE criteria for suspicious lesions
- Dermoscopy findings if performed
- Distribution pattern (localized, scattered, symmetric)
- Surrounding skin condition
- Photography documentation reference
Sample Phrases:
Assessment
Clinical diagnosis, differential diagnoses, and pathology correlation
Key Elements:
- Primary diagnosis with ICD-10 code
- Differential diagnoses considered
- Clinical suspicion level for malignancy
- Dermoscopic impression
- Biopsy results correlation if available
- Pathology concordance/discordance
- Fitzpatrick skin type documentation
- Risk stratification
- Prognosis and recurrence risk
Sample Phrases:
Plan
Treatment plan, procedures, medications, and follow-up
Key Elements:
- Treatment modality (topical, systemic, procedural)
- Specific medications with strength and frequency
- Procedures planned or performed
- Biopsy technique and site
- Excision margins and closure method
- Pathology orders with clinical indication
- Patient education provided
- Sun protection counseling
- Follow-up timing and skin checks
- Referral to specialists if indicated
Sample Phrases:
Dermatology Lesion Terminology
Standardized morphologic descriptors for precise clinical documentation
1Primary Lesions
Macule
Flat, circumscribed discoloration <1cm
Examples: Freckle, café au lait spot
Patch
Flat, circumscribed discoloration >1cm
Examples: Vitiligo, port wine stain
Papule
Elevated solid lesion <1cm
Examples: Nevus, wart, molluscum
Plaque
Elevated flat-topped lesion >1cm
Examples: Psoriasis, eczema
Nodule
Palpable solid lesion >1cm
Examples: Lipoma, dermatofibroma
Tumor
Large solid mass >2cm
Examples: Squamous cell carcinoma
Vesicle
Fluid-filled blister <1cm
Examples: Herpes simplex, chickenpox
Bulla
Fluid-filled blister >1cm
Examples: Bullous pemphigoid, burn
Pustule
Pus-filled lesion
Examples: Acne, folliculitis
Wheal
Transient edematous papule/plaque
Examples: Urticaria, insect bite
2Secondary Changes
Scale
Accumulation of stratum corneum
Examples: Psoriasis, seborrheic dermatitis
Crust
Dried serum, blood, or pus
Examples: Impetigo, healing wound
Erosion
Partial thickness epidermal loss
Examples: Ruptured vesicle
Ulcer
Full thickness epidermal loss
Examples: Venous stasis ulcer
Fissure
Linear crack in epidermis
Examples: Angular cheilitis, hand eczema
Lichenification
Thickening with enhanced skin markings
Examples: Chronic eczema
Excoriation
Linear erosion from scratching
Examples: Prurigo nodularis
Atrophy
Thinning of skin
Examples: Steroid-induced, aged skin
ABCDE Criteria for Melanoma Screening
Melanoma screening criteria for evaluating suspicious pigmented lesions
Asymmetry
One half does not match the other half
Scoring: Score 0 (symmetric) or 1-2 (asymmetric in 1 or 2 axes)
Dermoscopy: Asymmetry of color, structure, or pattern
Border
Irregular, scalloped, or poorly defined edges
Scoring: Score 0 (smooth) to 8 (irregular in all octants)
Dermoscopy: Abrupt edge cutoff, peripheral streaking
Color
Multiple colors or color variegation
Scoring: Score based on number of colors (brown, black, red, white, blue-gray)
Dermoscopy: Multiple colors, blue-white veil, regression structures
Diameter
Lesion >6mm (size of pencil eraser)
Scoring: Track diameter changes over time
Dermoscopy: Measure accurately with dermoscopy ruler
Evolving
Changing in size, shape, color, or symptoms
Scoring: Document all changes reported by patient
Dermoscopy: Compare to baseline images if available
Clinical Pearl
Any pigmented lesion meeting 2 or more ABCDE criteria warrants biopsy or close monitoring. The "E" (Evolving) criterion is particularly important - any changing lesion should be evaluated. Document baseline photography for comparison.
Dermoscopy Documentation
Key dermoscopic patterns and features to document in dermatology notes
Benign Patterns
Reticular pattern
Network of pigmented lines
Seen in: Benign nevi
Globular pattern
Round to oval structures
Seen in: Nevi, dermatofibromas
Homogeneous pattern
Uniform diffuse pigmentation
Seen in: Nevi, blue nevi
Starburst pattern
Radial streaks symmetrically
Seen in: Spitz nevus, Reed nevus
Malignant Features
Atypical network
Irregular, widened pigment network
Seen in: Melanoma
Blue-white veil
Irregular confluent blue pigmentation
Seen in: Melanoma
Irregular streaks
Asymmetric radial streaming
Seen in: Melanoma
Irregular dots/globules
Varying size, shape, color
Seen in: Melanoma
Regression structures
White scar-like areas, peppering
Seen in: Melanoma
Atypical vessels
Polymorphous, dotted, linear irregular
Seen in: Melanoma, BCC, SCC
Non-melanocytic Patterns
Arborizing vessels
Branching telangiectasias
Seen in: Basal cell carcinoma
Keratin pearls
White-yellow structures
Seen in: Seborrheic keratosis, SCC
Milia-like cysts
White-yellow globules
Seen in: Seborrheic keratosis
Central white scale
Central white/yellow scale with vessels
Seen in: Warts
Clinical Photography Standards
Standardized clinical photography is essential for documentation, monitoring, and medicolegal purposes
Equipment
- HIPAA-compliant imaging system
- Standardized lighting (ring flash or LED)
- Macro lens capability for close-ups
- Ruler or scale marker visible
- Color calibration card when possible
Patient Positioning
- Consistent distance from camera
- Neutral background (blue or gray)
- Remove jewelry/clothing as appropriate
- Document anatomic landmarks
- Reproducible positioning for follow-up
Views Required
- Overview image showing anatomic location
- Close-up of lesion with ruler (millimeter scale)
- Dermoscopic image if performed
- Surrounding skin for context
- Multiple angles if three-dimensional
Documentation
- Date and time of photography
- Patient identifier visible or embedded
- Lesion location documented in chart
- Reference photography number in note
- Informed consent for photography
Complete Dermatology SOAP Note Examples
Real clinical examples for common dermatologic conditions
Acne Vulgaris
Subjective
Patient reports persistent facial breakouts for 6 months. Tried over-the-counter benzoyl peroxide with minimal improvement. Comedones and inflammatory papules worsening. Denies cosmetic triggers. No prior systemic acne therapy.
Objective
Facial exam: Multiple open and closed comedones on forehead and nose. 10-15 erythematous papules and pustules on cheeks and chin. No nodules or cysts. Mild post-inflammatory hyperpigmentation. No scarring. Fitzpatrick skin type IV.
Assessment
Moderate inflammatory acne vulgaris (L70.0). Predominant comedonal and papulopustular components. No nodulocystic features.
Plan
Initiate tretinoin 0.025% cream nightly (start 3x/week, increase as tolerated). Add clindamycin 1% gel AM. Continue benzoyl peroxide 5% wash. Counsel on skincare routine and retinoid dermatitis expectations. Follow up in 6 weeks to assess response. Consider oral antibiotics if inadequate response.
Psoriasis Vulgaris
Subjective
Patient presents with persistent scaly plaques on elbows and knees for 2 years. Worsens in winter. Tried topical hydrocortisone without improvement. No joint pain. No prior psoriasis diagnosis. Father has psoriasis.
Objective
Well-demarcated erythematous plaques with silvery-white scale on bilateral elbows (3-5cm) and knees (4-6cm). Auspitz sign positive. No nail pitting or onycholysis. BSA involvement approximately 5%. No scalp or inverse involvement visible.
Assessment
Plaque psoriasis, localized (L40.0). Mild to moderate severity based on BSA <10%. Classic plaque morphology. Family history positive.
Plan
Initiate betamethasone dipropionate 0.05% ointment BID to plaques, maximum 2 weeks then taper to weekends only. Add calcipotriene 0.005% ointment on non-steroid days. Recommend coal tar shampoo if scalp involvement develops. Lifestyle: Moisturize regularly, avoid skin trauma (Koebner phenomenon). Follow up in 4 weeks. Discuss phototherapy or systemic therapy if inadequate response.
Atopic Dermatitis (Eczema)
Subjective
Patient reports intensely itchy rash in elbow creases and behind knees since childhood. Flares with stress and cold weather. Currently worse than baseline. Using fragrance-free moisturizers. History of asthma. Frequent nighttime scratching affecting sleep.
Objective
Bilateral antecubital and popliteal fossae demonstrate ill-defined erythematous plaques with xerosis and lichenification. Excoriations present. No oozing or crusting. Mild involvement on wrists. Dennie-Morgan folds noted. Approximately 8% BSA involvement.
Assessment
Moderate atopic dermatitis (L20.9). Active flare with lichenification from chronic scratching. Typical flexural distribution. Personal history of atopy.
Plan
Short course triamcinolone 0.1% ointment BID to active areas x 2 weeks. Transition to pimecrolimus 1% cream BID for maintenance. Aggressive moisturization with ceramide-containing products immediately after bathing. Hydroxyzine 25mg qHS PRN for pruritus. Recommend wet wrap therapy for severe flares. Identify and avoid triggers. Follow up in 3 weeks.
Basal Cell Carcinoma
Subjective
Patient noticed non-healing "sore" on left nasal ala for 6 months. Intermittently bleeds and crusts. No pain. Significant lifetime sun exposure as outdoor construction worker. No history of skin cancer. No radiation exposure.
Objective
5mm pearly, pink papule with telangiectasias on left nasal ala. Central depression with intermittent crusting. Rolled borders. Dermoscopy: Arborizing vessels, multiple blue-gray ovoid nests, spoke-wheel structures. Concerning for basal cell carcinoma. Facial examination otherwise unremarkable.
Assessment
Nodular basal cell carcinoma, left nasal ala (C44.319). Clinical and dermoscopic features highly suspicious. Cosmetically sensitive location.
Plan
3mm punch biopsy performed today, sent to pathology (spec #2024-12345, clinical indication: rule out BCC). Once pathology confirms, will schedule Mohs micrographic surgery given facial location and importance of tissue preservation. Discussed BCC diagnosis, treatment options, and excellent prognosis. Full skin exam: No additional concerning lesions. Recommend annual skin surveillance exams. Sun protection counseling provided.
Melanoma In Situ
Subjective
Patient reports changing mole on upper back noted by spouse. Lesion darker and larger than 6 months ago. No bleeding or itching. No personal history of melanoma. Mother diagnosed with melanoma at age 65. Multiple dysplastic nevi. Uses sunscreen inconsistently.
Objective
8mm irregularly bordered, asymmetric, variegated brown to black macule on upper back. ABCDE: A=2, B=irregular in 6 segments, C=3 colors, D=8mm, E=patient reports growth. Dermoscopy: Atypical pigment network, irregular globules, peripheral streaking, focal regression. Multiple additional nevi with some dysplastic features throughout back.
Assessment
Atypical pigmented lesion, highly suspicious for melanoma (D03.9). ABCDE score: concerning. Dermoscopic features consistent with melanoma. Multiple dysplastic nevi syndrome. Strong family history melanoma.
Plan
Complete excisional biopsy with 2mm margins performed today (sent to pathology, spec #2024-12346). Await pathology for definitive diagnosis and Breslow depth. If melanoma confirmed, will stage and determine need for re-excision based on depth. Baseline total body photography ordered for dysplastic nevus monitoring. Discussed melanoma risk factors, signs to monitor, strict sun protection. Follow up in 2 weeks for pathology results. Recommend dermatology surveillance q3-6 months given high-risk profile.
Rosacea
Subjective
Patient complains of persistent facial redness and flushing for 2 years, worsening over past 6 months. Triggers include spicy foods, alcohol, hot beverages. Multiple small facial bumps. Denies eye symptoms. Tried over-the-counter products without benefit.
Objective
Centrofacial erythema involving cheeks, nose, and chin. Multiple small erythematous papules and pustules, no comedones. Visible telangiectasias on cheeks. No rhinophyma. No ocular injection or irritation. Fitzpatrick skin type II.
Assessment
Papulopustular rosacea, moderate (L71.9). Classic centrofacial distribution with inflammatory papules and vascular component.
Plan
Initiate metronidazole 0.75% gel BID. Add azelaic acid 15% gel daily if tolerated after 2 weeks. Consider doxycycline 40mg (anti-inflammatory dose) daily if topicals insufficient. Trigger avoidance counseling. Recommend gentle skincare, mineral sunscreen SPF 30+. Refer to laser/IPL for persistent erythema and telangiectasias if medical therapy insufficient. Follow up in 8 weeks.
Dermatology Procedure Documentation
Essential elements for documenting common dermatologic procedures
Shave Biopsy
ProcedureIndication:
Sampling of superficial lesions (SK, suspected BCC/SCC)
Technique:
After informed consent and timeout, site prepped with alcohol. 1% lidocaine with epinephrine infiltrated. Lesion shaved tangentially with #15 blade at level of mid-dermis. Hemostasis achieved with aluminum chloride. Specimen submitted in formalin to pathology.
Sample Documentation:
Procedure note: Shave biopsy of 6mm papule, left cheek. Lidocaine 1% with epi 1.5mL. Specimen to pathology (spec #). Post-procedure care instructions given. Wound care: Petrolatum and bandage, keep moist. RTC for results in 1-2 weeks.
Punch Biopsy
ProcedureIndication:
Full-thickness sampling of inflammatory conditions or deeper lesions
Technique:
After informed consent and timeout, site prepped. 1% lidocaine with epinephrine infiltrated. 3mm/4mm punch used to obtain full-thickness cylindrical specimen. Specimen submitted. Hemostasis with pressure and/or simple suture closure.
Sample Documentation:
Procedure note: 4mm punch biopsy, left forearm rash. Lidocaine 1% with epi 2mL. One simple interrupted 4-0 nylon suture placed. Specimen to pathology (spec #) for H&E and DIF. Suture removal in 7-10 days. Wound care instructions provided.
Excisional Biopsy
ProcedureIndication:
Complete removal of lesion with margins for histologic diagnosis
Technique:
After informed consent and timeout, lesion and margins marked. Site prepped, draped. Lidocaine 1% with epinephrine infiltrated. Elliptical excision with 2-4mm margins to subcutaneous fat. Specimen oriented with suture. Undermining as needed. Layered closure.
Sample Documentation:
Procedure note: Excisional biopsy, suspicious pigmented lesion, upper back. Ellipse 15x6mm with 2mm margins. Undermining, layered closure with 4-0 Monocryl deep, 5-0 nylon superficial (8 sutures). Specimen oriented (short=superior) to pathology (spec #). Suture removal in 10-14 days. Discussed pathology follow-up.
Cryotherapy
ProcedureIndication:
Treatment of benign lesions (warts, actinic keratoses, seborrheic keratoses)
Technique:
Liquid nitrogen applied via spray or cryoprobe. Freeze-thaw cycles tailored to diagnosis: AK (5-10 sec), wart (10-30 sec with 1-2mm margin), SK (variable). White halo achieved. Patient counseled on expected blistering.
Sample Documentation:
Procedure note: Cryotherapy to 4 actinic keratoses on bilateral forearms (10 seconds each) and 1 viral wart on left hand (20 seconds x 2 cycles with 2mm margin). Anticipated blistering and hypopigmentation discussed. Return PRN if persistence. Skin cancer screening counseling provided.
Mohs Micrographic Surgery
ProcedureIndication:
Treatment of high-risk or cosmetically sensitive skin cancers
Technique:
Multi-stage procedure with immediate microscopic margin control. Surgical layers removed sequentially, mapped, processed, examined. Additional layers removed until margins clear. Reconstruction performed after tumor clearance.
Sample Documentation:
Mohs surgery, BCC left nasal ala. Stage 1: 6mm defect, positive margins at 3 o'clock. Stage 2: Additional tissue removed, margins clear. Final defect 9x8mm. Repaired with advancement flap. Layered closure. Post-op care discussed. Follow up in 1 week for suture removal, then 6 months for surveillance.
Cosmetic Procedure Documentation
Cosmetic dermatology procedures require thorough documentation for medical-legal protection
Essential Documentation Elements
- Pre-procedure photography (multiple angles)
- Informed consent with risks, benefits, alternatives
- Patient expectations and treatment goals discussed
- Areas treated with specific anatomic sites
- Product used (lot number, expiration date)
- Units/volume/concentration administered
- Injection technique and depth
- Adverse events or complications
- Post-procedure instructions and follow-up plan
- Patient satisfaction assessment at follow-up
Botulinum Toxin (Botox)
Cosmetic consultation: Glabellar lines treatment. Pre-procedure photos obtained. Informed consent signed. BOTOX 20 units total (Lot #ABC123, Exp 12/2026) injected to glabellar complex: 5 injection points. No bleeding/bruising. Post-procedure care: Avoid lying flat 4 hours, no exercise 24 hours. Expect onset 3-7 days, peak 2 weeks. Follow up PRN in 2 weeks.
Dermal Fillers
Cosmetic consultation: Volume loss nasolabial folds. Pre-procedure photos. Consent reviewed. Juvederm Ultra Plus 1.0mL injected into right nasolabial fold, 1.0mL left nasolabial fold via linear threading and serial puncture. Immediate molding. Minimal bruising. Ice applied. Discussed expected swelling 24-48 hours. Arnica recommended. Emergency contact provided. Follow up in 2 weeks.
Dermatology ICD-10 Codes
Common diagnostic codes for dermatologic conditions
Benign Neoplasms
Melanocytic nevi (x=site: 5=trunk, 6=upper limb, 7=lower limb, 9=unspecified)
Other benign neoplasms of skin (site-specific)
Inflamed seborrheic keratosis
Other seborrheic keratosis
Malignant Neoplasms
Malignant melanoma of skin (site-specific)
Basal cell carcinoma of skin (site-specific, laterality)
Squamous cell carcinoma of skin (site-specific, laterality)
Melanoma in situ (site-specific)
Carcinoma in situ of skin (site-specific)
Inflammatory Conditions
Atopic dermatitis, unspecified
Dermatitis, unspecified (eczema)
Psoriasis vulgaris
Arthropathic psoriasis, unspecified
Acne vulgaris
Rosacea, unspecified
Infections
Viral wart, unspecified
Herpesviral vesicular dermatitis (HSV)
Zoster without complications (shingles)
Impetigo, unspecified
Cellulitis, unspecified
Dermatophytosis, unspecified (tinea)
Precancerous Lesions
Actinic keratosis
Carcinoma in situ of skin of scalp and neck
Common Documentation Mistakes
Avoid these frequent dermatology documentation errors
Vague lesion descriptions
Problem:
Documentation like "rash on arm" lacks specificity for diagnosis and billing
Solution:
Use precise morphology: "3cm well-demarcated erythematous plaque with silvery scale on left extensor forearm"
Impact:
Billing denials, medicolegal vulnerability, poor care continuity
Missing lesion measurements
Problem:
Not documenting size makes monitoring and excision planning impossible
Solution:
Always measure and document lesions in millimeters (length x width). Include reference photos.
Impact:
Cannot track growth, inadequate excision margins, no baseline for comparison
Incomplete ABCDE assessment for pigmented lesions
Problem:
Failure to systematically evaluate melanoma criteria increases missed diagnoses
Solution:
Document all five ABCDE criteria for every pigmented lesion, even if benign-appearing
Impact:
Missed melanoma, malpractice risk, poor quality metrics
Not documenting dermoscopy findings
Problem:
Performing dermoscopy without documentation provides no medicolegal protection
Solution:
Document dermoscopic structures seen: "Dermoscopy: Regular pigment network, no blue-white veil"
Impact:
No evidence dermoscopy performed, liability if cancer missed
Omitting photography references
Problem:
Taking clinical photos but not referencing them in documentation
Solution:
Document: "Clinical photographs obtained and uploaded to chart, images #12345-12348"
Impact:
Photos not linked to visit, lost documentation value
Inadequate procedure documentation
Problem:
Brief notes like "biopsy performed" lack critical procedural details
Solution:
Include: site, size, technique, anesthesia, closure, specimen handling, pathology order, complications
Impact:
Billing denials, quality issues, medicolegal problems
Missing pathology correlation
Problem:
Not documenting how pathology results align (or don't align) with clinical diagnosis
Solution:
State: "Pathology confirms clinical diagnosis of BCC" or "Pathology shows melanoma, discordant with clinical impression"
Impact:
Poor care coordination, missed treatment modifications
No sun protection counseling documentation
Problem:
Counseling not documented means it didn't happen from billing/legal perspective
Solution:
Document: "Discussed sun protection, daily SPF 30+, sun-protective clothing, annual skin exams"
Impact:
Lost preventive care credit, reduced quality scores
Frequently Asked Questions
What is the ABCDE rule for melanoma screening?
The ABCDE rule helps identify suspicious pigmented lesions: A=Asymmetry (one half doesn't match the other), B=Border irregularity (scalloped or poorly defined edges), C=Color variation (multiple colors or uneven distribution), D=Diameter >6mm (size of pencil eraser), and E=Evolving (changing in size, shape, color, or symptoms). Lesions meeting multiple criteria should be biopsied or monitored closely.
What dermatology-specific elements must be documented in SOAP notes?
Dermatology SOAP notes require: anatomic location of lesions, size in millimeters, primary morphology (macule, papule, plaque, etc.), color, border characteristics, distribution pattern, ABCDE criteria for pigmented lesions, dermoscopy findings if performed, photography reference, body diagram mapping, and Fitzpatrick skin type. Procedures require technique, anesthesia, specimen handling, and pathology orders.
How should I describe skin lesion morphology?
Use standardized dermatologic terminology. Primary lesions: macule (flat <1cm), patch (flat >1cm), papule (raised <1cm), plaque (raised flat-topped >1cm), nodule (solid >1cm), vesicle (fluid <1cm), bulla (fluid >1cm), pustule (pus-filled). Secondary changes: scale, crust, erosion, ulcer, lichenification, atrophy. Always include size, color, location, and distribution.
What dermoscopy findings suggest melanoma?
Concerning dermoscopic features include: atypical pigment network (irregular, widened), blue-white veil (irregular confluent blue pigmentation), irregular streaks (asymmetric radial streaming), irregular dots and globules (varying size/color), regression structures (white scar-like areas, blue-gray peppering), and atypical vessels. Multiple features increase suspicion; biopsy recommended.
How do I document skin cancer excisions properly?
Document: informed consent, timeout, site prep/drape, anesthesia type and amount, lesion location and size, excision margins planned (usually 4mm for BCC, variable for SCC, 5-10mm for melanoma based on Breslow depth), technique, specimen orientation (e.g., "suture marks superior"), closure method (layers, suture type/size), complications, pathology order, and post-op instructions including suture removal timing.
What ICD-10 codes are most common in dermatology?
Common codes include: L70.0 (acne vulgaris), L40.0 (psoriasis vulgaris), L20.9 (atopic dermatitis), L71.9 (rosacea), L57.0 (actinic keratosis), C44.x1 (basal cell carcinoma), C44.x2 (squamous cell carcinoma), C43.x (melanoma), D22.x (benign nevi), and B07.9 (viral warts). The "x" represents site-specific digits requiring anatomic location.
How should clinical photography be documented?
Document: patient consent obtained, date/time of photos, anatomic location photographed, image reference numbers, equipment used, presence of scale/ruler in close-ups, and purpose (baseline, monitoring, pre/post-procedure). Store in HIPAA-compliant system. Reference photos in clinical note: "Clinical photographs obtained, images #12345-12348." Photos should include overview and close-up with ruler.
Can AI help with dermatology documentation?
Yes, AI documentation tools like PatientNotes can capture dermatology visits and generate SOAP notes with appropriate lesion descriptions, ABCDE criteria, dermoscopy findings, and procedure documentation. The AI can prompt for dermatology-specific elements like measurements, morphology, and body mapping. This saves 10-15 minutes per visit while ensuring complete documentation. Providers review and sign final notes.
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