Quick Way to Write Esthetician SOAP Notes

Esthetician SOAP Notes

It's the end of a long day at the spa, and you've got six client files sitting on your desk that need proper documentation before you can finally head home.

Your last facial client had a complicated skin history with multiple sensitivities, and you're trying to remember every detail about the products you used and how her skin reacted.

Sound familiar? If you've ever felt overwhelmed by client documentation while running a busy esthetics practice, you're not alone.

We've all been there.

Quick Tip:

SOAP Notes Doctor is our product that transforms recordings, audios, and text into industry-standard SOAP notes for estheticians.

You can record your treatment notes right after each client and let the system do the work.

You can edit, review, and add more context later.

Head over to soapnotes.doctor now.

Let's dive in.

SOAP Notes: The Quick Story

Back in the day, esthetician documentation was all over the place.

One esthetician might keep detailed journals about every client's skin journey, while another would scribble "did facial - client happy" on an index card.

Some tracked product reactions meticulously, others relied purely on memory.

However, in the late 60s, things changed in the medical field with Dr. Lawrence Weed, the man who really said "we can do better."

He created a standardized system called the Problem-Oriented Medical Record, with SOAP notes as its cornerstone.

His brilliant idea was simple: give everyone the same template so any professional could read someone else's notes and actually understand what happened.

While SOAP notes started in medicine, they quickly became the gold standard for any field requiring thorough client documentation—including esthetics.

Here's what the SOAP format looks like:

• S (Subjective): What your client tells you about their skin concerns and goals
• O (Objective): What you observe during the skin analysis and treatment
• A (Assessment): Your professional evaluation of the client's skin condition
• P (Plan): Your treatment recommendations and home care plan

This format caught on like wildfire because it just made sense.

Soon it spread from hospitals to dermatology clinics, medical spas, and professional esthetics practices everywhere.

Why SOAP Notes Matter for Estheticians

You might be thinking, "I'm not a doctor, do I really need all this documentation?"

The answer is absolutely yes, and here's why:

Legal Protection: Detailed notes protect you if a client claims they had a reaction or that you didn't inform them of something.

Continuity of Care: When a client returns six months later, you need to know exactly what you did and how their skin responded.

Professional Credibility: Proper documentation shows you're a serious professional, not just someone who does facials.

Business Growth: Good records help you track which treatments work best for different skin types, making you a better esthetician.

Insurance Requirements: If you work in a medical spa or want to get credentialed, SOAP notes are often required.

How to Write SOAP Notes for Estheticians: My Recommended Approach

When I started building tools for estheticians, I discovered something interesting.

The best estheticians weren't the ones writing the longest notes—they were the ones who captured what mattered most efficiently.

"Document the essentials. Don't write a novel."

Be clear, be specific, but don't overthink it. Write like you're talking to another esthetician who needs to pick up where you left off.

There are technically two ways you can approach SOAP notes. You can write them manually, or you can write them using soapnotes.doctor.

Use soapnotes.doctor

I'll choose soapnotes.doctor every day since it's consistent, accurate, and most importantly, faster than handwritten notes.

Here's how to streamline the whole process:

1. Head over to soapnotes.doctor to get started. Complete the onboarding process if you're new to the platform.

2. Click on the record button to either record notes right after your treatment or dictate key observations while they're fresh in your mind.

3. Wait 1-3 minutes.

4. Review and save.

One beauty of soapnotes.doctor is that the tool is just good. Not superfluous, yet never misses detail. I think that's the best of both worlds.

And if for whatever reason you choose to make edits, you have the tailor feature at your disposal. Edit, approve, add context, and save to your client management system.

Write Manually

Maybe you prefer the hands-on approach of writing yourself. Here's how to make it efficient and effective.

1. S - Subjective

This is where you capture everything your client tells you about their skin.

This section should document your client's concerns, goals, and skin history in their own words.

Purpose: Record what your client reports about their skin condition, concerns, and expectations.

What to include:

• Chief concern or reason for visit
• Current skincare routine (products and frequency)
• Skin sensitivities or allergies
• Previous treatments and results
• Lifestyle factors (sun exposure, diet, stress, hormones)
• Client's goals for treatment

Examples:

"Client reports struggling with persistent breakouts along jawline for past 3 months, rates concern level as 8/10. States she recently started new birth control and suspects hormonal connection. Currently using drugstore cleanser twice daily and moisturizer at night. No known product allergies but reports stinging sensation with vitamin C products. Works outdoors, estimates 4+ hours daily sun exposure. Goal is to reduce breakouts and prevent scarring."

"Client presents for anti-aging treatment, concerned about fine lines around eyes and nasolabial folds. Reports using basic cleanser and moisturizer with SPF 30 daily. Has never had professional treatments. No allergies or sensitivities. Non-smoker, drinks 6-8 glasses water daily. Interested in looking 'refreshed' for daughter's wedding in 3 months."

2. O - Objective

This is where you document your professional observations during the skin analysis.

The objective section records measurable findings and your observations during the consultation and treatment.

Purpose: Document factual, observable data about the client's skin condition.

What to include:

• Fitzpatrick skin type
• Skin condition (oily, dry, combination, dehydrated)
• Visible concerns (acne, hyperpigmentation, texture, etc.)
• Sensitivity level
• Treatment performed
• Products used
• Client's response during treatment

Examples:

"Fitzpatrick Type III skin with combination condition—oily T-zone, normal cheeks. Visible inflammatory papules and pustules concentrated on lower face and jawline (approximately 15-20 active lesions). Post-inflammatory hyperpigmentation noted from previous breakouts. Mild texture irregularities. No visible sensitivity during analysis. Performed deep cleansing facial with extractions, applied 2% salicylic acid treatment, concluded with calming mask and broad-spectrum SPF 50. Client tolerated treatment well with no adverse reactions."

"Fitzpatrick Type II skin, mature, showing moderate signs of photoaging. Fine lines present around orbital area and nasolabial folds. Mild laxity noted. Some uneven pigmentation on cheeks consistent with sun damage. Skin appears dehydrated with slightly rough texture. Performed hydrating European facial with gentle enzyme exfoliation, applied hyaluronic acid serum, facial massage focusing on lymphatic drainage, finishing with peptide cream and SPF 45. Client found treatment relaxing and reported no discomfort."

3. A - Assessment

This section provides your professional analysis of the client's skin and treatment response.

Purpose: Connect what the client told you with what you observed, and evaluate the treatment outcome.

Key Principle: Focus on your professional evaluation and how the treatment addressed the client's concerns.

What to include:

• Professional skin analysis summary
• Primary and secondary skin concerns
• Contraindications noted
• Treatment effectiveness
• Factors affecting skin condition

Examples:

"Client presenting with inflammatory acne consistent with hormonal pattern (lower face distribution). Skin barrier appears compromised, likely from over-cleansing and lack of proper moisturization. Sun exposure without adequate protection contributing to post-inflammatory hyperpigmentation. Client responded well to extraction and salicylic acid treatment with no adverse reactions. Current home care routine insufficient for addressing acne and preventing sun damage."

"Mature skin showing expected signs of intrinsic and extrinsic aging. Dehydration is exacerbating appearance of fine lines. Client is good candidate for regular hydrating treatments and possibly chemical peels in future. Skin tolerated today's treatment excellently. Client would benefit from upgraded home care routine focusing on hydration, antioxidants, and consistent sun protection."

4. P - Plan

This final section outlines your recommendations for ongoing treatment and home care.

Purpose: Establish clear next steps for optimal skin health and results.

What to include:

• Home care product recommendations
• Frequency of professional treatments
• Next treatment focus
• Lifestyle recommendations
• Follow-up timeline

Examples:

"Recommended home care: gentle non-foaming cleanser AM/PM, 2% salicylic acid serum PM only (start 3x weekly), oil-free moisturizer with niacinamide AM/PM, mineral SPF 50 daily. Advised to avoid picking lesions to prevent scarring. Recommended monthly deep cleansing facials for next 3 months, then reassess. Consider adding chemical peel treatments once active breakouts improve. Follow-up in 4 weeks to monitor progress and adjust protocol as needed."

"Recommended home care upgrade: hydrating cleanser, hyaluronic acid serum, peptide moisturizer AM/PM, retinol serum 2-3x weekly PM (start low and slow), vitamin C serum AM, SPF 45+ daily. Advised increasing water intake and using humidifier at night. Suggested monthly hydrating facials leading up to wedding, incorporating gentle chemical peels starting next month. Scheduled next appointment in 4 weeks for hydrating facial with mild enzyme peel. Client expressed interest in learning proper home facial massage techniques."

Complete SOAP Note Examples for Estheticians

Now let's look at three complete examples that bring all these components together.

Example 1: Acne Treatment - First Visit

Client: 24-year-old female
Service: Deep cleansing acne facial
Visit Type: New client consultation and treatment

S – Subjective:

Client reports persistent acne breakouts for approximately 6 months, worsening over past 2 months. Rates frustration level with skin at 9/10. States breakouts are primarily on chin, jawline, and some on forehead. Reports painful cystic lesions that take weeks to heal. Recently stopped taking birth control pills (3 months ago) and suspects this triggered the acne flare-up. Current skincare routine: benzoyl peroxide wash twice daily, alcohol-based toner, drugstore moisturizer "when skin feels dry." Reports skin feels tight and sometimes flaky but still gets oily by midday. No known allergies but states some products cause burning sensation. Has never had professional facial treatment. Picks at breakouts "when stressed." Works from home, minimal sun exposure. Goal is to clear existing acne and prevent scarring. Willing to commit to professional treatments and upgrade home care routine.

O – Objective:

Fitzpatrick Type II skin presenting with combination condition—dehydrated with oily T-zone. Numerous inflammatory lesions present: approximately 8-10 cystic papules on chin and jawline (painful to touch), 15-20 smaller pustules and papules across lower face and forehead. Multiple areas of post-inflammatory hyperpigmentation and erythema from healing lesions. Visible picking scars on chin. Rough skin texture. Compromised barrier evident from flaking and tight feeling despite oil production. No visible sensitivity or redness during initial analysis. Performed thorough double cleanse, applied pre-extraction enzyme mask (10 minutes), steam, careful extractions on pustules (avoided inflamed cystic areas), applied 2% salicylic acid spot treatment to active lesions, calming LED light therapy (blue light, 15 minutes), soothing gel mask, lightweight oil-free moisturizer, mineral SPF 40. Client tolerated treatment well, reported relief from extractions. Educated client on proper extraction technique and dangers of picking.

A – Assessment:

Client presenting with moderate inflammatory acne with hormonal pattern consistent with discontinuation of oral contraceptives. Skin barrier is significantly compromised from aggressive over-cleansing and use of harsh products, creating cycle of dehydration and compensatory oil production. This barrier damage is likely worsening acne and preventing healing. Post-inflammatory hyperpigmentation present but will improve once active breakouts are controlled. Client's picking behavior is contributing to scarring and prolonging healing time. Home care routine is inappropriate for skin type and condition—stripping skin without proper hydration or treatment actives. Client demonstrates good motivation for treatment compliance and realistic expectations. Responded well to today's treatment with no adverse reactions. Will require consistent professional treatments combined with appropriate home care for 3-6 months to see significant improvement.

P – Plan:

Home Care Recommendations: Switch to gentle, non-foaming cream cleanser AM/PM. Discontinue alcohol toner immediately. Introduce barrier repair moisturizer with ceramides and niacinamide AM/PM. Add 2% salicylic acid leave-on treatment 3x weekly PM (increase gradually). Implement mineral SPF 30+ daily, even when working from home. Provided sample sizes of recommended products for client to trial.

Professional Treatment Plan: Scheduled monthly deep cleansing facials for next 3 months with focus on extractions, barrier repair, and calming treatments. Will incorporate chemical peels (lactic acid or mandelic acid) starting visit 3 once barrier is repaired. Recommended LED light therapy as add-on to reduce inflammation.

Lifestyle Recommendations: Advised to stop picking—suggested keeping hands busy with stress ball, applying pimple patches to prevent touching. Change pillowcases 2-3x weekly. Avoid touching face during work day.

Follow-up: Scheduled next appointment in 4 weeks. Client to text photos in 2 weeks to monitor progress and adjust protocol if needed. Provided educational handout on hormonal acne and barrier repair. Client verbalized understanding of treatment plan and expressed commitment to following recommendations.

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Example 2: Anti-Aging Treatment - Established Client

Client: 52-year-old female
Service: Hydrating facial with chemical peel
Visit Type: Monthly maintenance, 6th visit

S – Subjective:

Client reports skin is feeling "much better" since starting new home care routine 5 months ago. States fine lines around eyes are "definitely less noticeable" and skin feels more plump and hydrated. Compliant with all recommended products—using retinol 4x weekly now without irritation (started at 2x weekly). Applied SPF 45 daily without missing days. Attended daughter's wedding last month and reports receiving numerous compliments on skin. Some increased dryness noted over past 2 weeks due to indoor heating. No new concerns. Interested in discussing options for addressing neck lines and chest discoloration. No changes to health status or medications. Goal is to maintain current improvements and address new areas of concern.

O – Objective:

Fitzpatrick Type II mature skin showing continued improvement from previous visits. Fine lines around eyes and mouth appear softened compared to initial visit photos reviewed with client. Skin texture smoother and more even. Hydration level significantly improved—skin appears plump with healthy glow. Mild residual sun damage on cheeks but improved from baseline. Some neck laxity and horizontal lines noted. Chest showing moderate hyperpigmentation from previous sun exposure. Performed double cleanse, applied 20% lactic acid peel to face (8 minutes), neutralized, gentle extractions on nose, hydrating hyaluronic acid mask, facial massage with vitamin C serum, peptide moisturizer, SPF 45. Extended treatment to include neck and chest: gentle exfoliation, brightening serum application, peptide cream. Client tolerated peel well with expected light tingling, no adverse reactions.

A – Assessment:

Established client showing excellent response to consistent professional treatments and compliant home care routine over past 6 months. Skin health has improved significantly with enhanced barrier function, hydration, and texture. Fine lines softened and overall appearance more youthful. Client's commitment to SPF use is preventing further photodamage. Tolerance to retinol has progressed appropriately. Neck and chest showing signs of photoaging and volume loss consistent with age—these areas will require focused treatment plan separate from face. Client is ideal candidate for more aggressive treatments on these areas including stronger peels or targeted serums. Current treatment protocol for face should be maintained for optimal results.

P – Plan:

Home Care - Face: Continue current routine with no changes. Retinol 4x weekly PM, vitamin C serum AM, peptide moisturizer AM/PM, hyaluronic acid serum under moisturizer, SPF 45+ daily. All products working well.

Home Care - Neck/Chest: Add treatment to these areas. Recommended extending retinol application to neck 2-3x weekly. Apply vitamin C serum to chest and neck AM. Use SPF on neck and chest daily (client admits currently forgetting this area). Provided neck firming cream sample to trial.

Professional Treatment Plan: Continue monthly facials with alternating treatments—hydrating facial one month, chemical peel the next. Next visit will focus on neck and chest with specialized treatment including enzyme exfoliation and brightening mask for chest discoloration.

Additional Recommendations: Consider adding facial cupping or gua sha to future treatments for neck and jawline. Discussed microneedling as future option for neck texture.

Follow-up: Scheduled next appointment in 4 weeks for neck and chest focused treatment. Will take progress photos at that visit to document improvements. Client expressed satisfaction with current results and excitement about addressing neck and chest concerns.

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Example 3: Sensitive Skin - Rosacea Management

Client: 38-year-old male
Service: Calming sensitive skin facial
Visit Type: Second visit, follow-up from initial consultation 6 weeks ago

S – Subjective:

Client reports significant improvement in redness and irritation since first visit. States skin feels "calmer" overall, rates improvement at 7/10. Following recommended gentle skincare routine consistently. Using gentle cleanser AM/PM, barrier repair moisturizer, and mineral SPF 50 as directed. Reports fewer flare-ups—had only 2 episodes of significant redness in past 6 weeks versus daily prior to treatment. Identified triggers: spicy food, red wine, and hot showers (working on avoiding these). Stopped using all previous products that contained fragrance or essential oils. No burning or stinging with new products. Reports coworkers have commented that his skin looks better. Still experiences some redness on cheeks and nose but much less intense. Concerned about visible blood vessels on nose. Works outdoors for construction company, now applying SPF throughout day as recommended. No new medications or health changes.

O – Objective:

Fitzpatrick Type I skin with rosacea, subtype 1 (erythematotelangiectatic). Overall redness significantly reduced compared to initial visit—approximately 60% improvement per photographic comparison. Background erythema still present but less intense, particularly on cheeks and nose. Telangiectasia visible on nasal sidewalls and alar area. No papules or pustules present (client had 3-4 at initial visit). Skin texture smooth. No visible flaking or irritation. Barrier function appears improved. Performed gentle cream cleanse, applied cooling gel mask with chamomile and aloe (20 minutes), LED light therapy (yellow/green light, 20 minutes), barrier repair serum, calming moisturizer, mineral SPF 50. Avoided steam, kept water temperature cool, used light pressure for all massage. Client tolerated treatment excellently with no reactive redness.

A – Assessment:

Client with diagnosed rosacea showing excellent response to gentle skincare protocol and trigger avoidance. Significant reduction in baseline erythema and inflammatory flare-ups demonstrates improved barrier function and better disease management. Client's compliance with product recommendations and lifestyle modifications is evident in clinical improvement. Remaining telangiectasia on nose will not respond to topical treatments and would require laser or IPL if client wishes to address. No new inflammatory lesions suggest effective management of subtype 1 rosacea. Client is good candidate for maintenance treatment schedule. Construction work presents ongoing challenge for SPF compliance and environmental triggers (heat, sun exposure).

P – Plan:

Home Care: Continue current routine—extremely effective for client's skin. No changes needed. Gentle cleanser AM/PM, barrier repair moisturizer AM/PM, mineral SPF 50 (reapply every 2 hours during outdoor work). Reinforced importance of trigger avoidance, particularly heat exposure.

Professional Treatment Plan: Recommend monthly calming facials for maintenance. These treatments help control inflammation and support barrier function. Continue with LED light therapy as it's showing good results. Consider incorporating lymphatic drainage massage in future visits to address redness.

Telangiectasia Discussion: Educated client that visible blood vessels on nose will not improve with facials or products alone. Discussed IPL (Intense Pulsed Light) or laser treatments as options if he wishes to address these. Provided referral to medical spa with laser services for consultation. Explained these treatments are optional and current routine is successfully managing his rosacea symptoms.

Lifestyle Recommendations: Suggested wearing wide-brimmed hat during outdoor work. Avoid hot showers (use lukewarm water). Keep face mist in work truck for refreshing skin during hot days. Continue avoiding known triggers.

Follow-up: Scheduled next appointment in 4-6 weeks. Will continue monthly facials as maintenance unless client experiences flare-up and needs sooner appointment. Client verbalized understanding and expressed satisfaction with progress. Provided written trigger list and rosacea educational materials.

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Additional Tips for Esthetician SOAP Notes

Be Specific About Products: Always document exactly which products you used during treatment and recommended for home care, including percentages of active ingredients.

Take Photos: Visual documentation is invaluable. Take consistent photos (same lighting, same angles) to track progress over time.

Document Contraindications: Note any reasons a client shouldn't receive certain treatments (medications, conditions, pregnancy, etc.).

Record Product Reactions: If a client has any reaction during treatment, document it thoroughly—this protects both of you.

Note Client Education: Document what you taught the client about their skin, proper product use, or technique.

Track Progress: Always compare current visit to previous visits to show improvement or need for protocol changes.

Professional Language: Use proper terminology for skin conditions and treatments to demonstrate your expertise.

Legal Protection: Remember that SOAP notes are legal documents that could be reviewed in case of disputes or insurance claims.

Implementing structured SOAP notes in your esthetics practice ensures excellent client care, demonstrates your professionalism, and provides invaluable records for tracking treatment effectiveness and protecting your business.