Complete Guide to Seborrheic Keratosis SOAP Note Examples for Dermatology Providers

If you've ever struggled to document seborrheic keratosis evaluations in a way that satisfies insurance requirements while remaining clinically useful, this guide is for you.

I've talked to countless dermatologists, family physicians, and nurse practitioners who spend excessive time documenting benign skin lesions to meet insurance documentation standards.

The reality is that dermatology documentation has specific requirements that go beyond basic medical notes.

Insurance companies want to see clear clinical descriptions, appropriate differential diagnosis, photographic documentation when available, and justification for any treatment or removal.

That's exactly why I built SOAP Notes Doctor to handle the heavy lifting of documentation while you focus on patient care.

In this article, I'll show you exactly how to write seborrheic keratosis SOAP notes that meet insurance standards, with real examples you can use as templates.

🧾 What SOAP Notes Really Are (And Why They Matter for Dermatology)

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose.

They were introduced in the 1960s by Dr. Lawrence Weed as part of the Problem-Oriented Medical Record (POMR).

His goal was straightforward: create a documentation system that anyone reviewing a chart could understand quickly and completely.

For dermatology specifically, SOAP notes are critical because they demonstrate:

• Clear clinical description of lesion characteristics
• Appropriate differential diagnosis and risk assessment
• Medical necessity for biopsy, removal, or treatment
• Documentation that distinguishes benign from concerning lesions

SOAP stands for:

• S — Subjective: What the patient reports about the lesion, including when noticed, changes over time, symptoms, and cosmetic concerns.
• O — Objective: Your clinical findings including lesion description, location, size, morphology, dermoscopic findings, and photographic documentation.
• A — Assessment: Your clinical diagnosis, differential diagnosis, and risk stratification distinguishing benign from malignant lesions.
• P — Plan: Your treatment plan including observation, cryotherapy, shave removal, patient education, and follow-up recommendations.

This structure keeps your documentation organized, defensible, and insurance-friendly.

You're not just recording what happened—you're building a clinical narrative that justifies treatment decisions and demonstrates appropriate care.

How You Can Approach Seborrheic Keratosis SOAP Notes

There's no single correct method for writing dermatology SOAP notes, but some approaches work better than others depending on your practice volume.

Here are two main approaches I've seen work well.

1. Traditional, Manual Documentation

This is the classic method: typing out each lesion description after each visit. It works if you have strong clinical writing skills and see a manageable number of patients daily. The challenge is it's time-consuming, especially when documenting multiple lesions, and descriptions can become inconsistent across providers.

2. SOAP Notes Doctor

You record your examination findings or dictate your lesion descriptions, and the tool automatically structures everything into proper SOAP format. It maintains consistency, saves hours of documentation time, and ensures you never miss critical components that insurance companies look for.

How to Make Seborrheic Keratosis SOAP Notes Faster

One of the biggest complaints I hear from dermatology providers is how documentation eats into their already packed schedules.

You've just finished a full day of skin checks, biopsies, and procedures, and instead of leaving on time, you're stuck typing detailed descriptions of every seborrheic keratosis you evaluated.

The pressure is real: make them too brief and you risk denials or liability issues; make them too detailed and you've just added hours to your day.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your examination findings or dictate lesion descriptions
✅ Generate properly formatted SOAP notes instantly
✅ Get your evenings and weekends back

With soapnotes.doctor, you can record during or right after a visit, add rough notes about specific findings, or even upload audio later. The system converts everything into insurance-compliant SOAP notes automatically.

You still get the clinical accuracy and thoroughness that insurance companies require, but without manually typing every detail.

Maybe you noted specific findings?

Left temple, 8mm, brown, stuck-on appearance, positive horn cysts on dermoscopy, patient wants removal for cosmetic reasons.

Use the tailorr feature to add them. Keep it raw and unpolished—soapnotes.doctor handles the rest.

Example 1: Single Seborrheic Keratosis, Cosmetic Removal Request

Patient: 58-year-old male
Chief Complaint: "Growth on my face that keeps getting caught when I shave"
Visit: Skin lesion evaluation

S – Subjective:

Patient reports noticing a brown, raised growth on left temple approximately 2 years ago. States it has slowly increased in size and now catches on his razor during shaving, occasionally causing minor bleeding. Denies pain, itching, or discharge from the lesion. No history of trauma to the area. Concerned about appearance and requests removal. No personal history of skin cancer. Family history significant for basal cell carcinoma in father at age 72. Patient works outdoors as a construction supervisor with significant cumulative sun exposure throughout career. Denies changes in color, rapid growth, or bleeding aside from shaving trauma.

O – Objective:

Vital Signs: Stable, patient comfortable
Skin Exam:

• Left temple: 8mm x 7mm well-demarcated, brown to tan, exophytic papule with stuck-on appearance and waxy surface texture. Borders are regular. Surface demonstrates multiple small horn cysts visible on close inspection. No inflammation, ulceration, or bleeding noted today. Lesion is pedunculated with narrow base.
• Dermoscopy: Multiple milia-like cysts (horn cysts), comedo-like openings, and fingerprint-like structures consistent with seborrheic keratosis. No atypical vascular patterns, blue-white veil, or irregular pigment network.
• Surrounding skin: Multiple smaller seborrheic keratoses on forehead and cheeks bilaterally, ranging 3-5mm, consistent clinical appearance.
• General skin exam: Fitzpatrick Type II skin, significant solar elastosis on face and forearms, multiple lentigines on dorsal hands, no suspicious pigmented lesions identified.

A – Assessment:

Seborrheic keratosis, left temple, clinically typical. Dermoscopic findings confirm benign diagnosis. No clinical features concerning for malignancy. Patient's cosmetic concerns and mechanical irritation from shaving represent reasonable indications for removal. Multiple additional seborrheic keratoses noted on face, monitoring appropriate.

P – Plan:

Lesion Removal: Discussed treatment options including observation, cryotherapy, and shave removal. Patient prefers shave removal for cosmetic result and to eliminate shaving irritation. Explained procedure, risks including bleeding, infection, scarring, hypopigmentation, and recurrence. Patient provided informed consent.

Procedure Performed: Area cleansed with alcohol. 1% lidocaine with epinephrine infiltrated at base of lesion, achieving adequate anesthesia. Shave excision performed using #15 blade at skin level. Hemostasis achieved with aluminum chloride. Wound dressed with antibiotic ointment and bandage. Specimen sent to pathology for histologic confirmation (routine seborrheic keratosis identification, low suspicion for malignancy).

Post-Procedure Care: Instructed to keep wound clean and dry for 24 hours, then may shower. Apply antibiotic ointment twice daily and keep covered with bandage until healed, typically 7-10 days. Expect pink scar that will fade over 3-6 months. Contact office if signs of infection develop including increasing redness, warmth, swelling, purulent drainage, or fever.

Skin Cancer Screening: Discussed patient's risk factors for skin cancer including fair skin type, significant sun exposure history, and family history. Recommended comprehensive full-body skin examination. Patient scheduled for complete skin check in 2 weeks to allow healing of current site.

Follow-up: Pathology results will be available in 7-10 days, patient will be contacted if any unexpected findings. Otherwise, return for full skin examination as scheduled. Patient instructed to monitor remaining seborrheic keratoses and report any changes in size, color, or symptoms. Patient verbalized understanding of all instructions.

Example 2: Multiple Seborrheic Keratoses, Screening Examination

Patient: 65-year-old female
Chief Complaint: Annual skin check, concerned about "age spots"
Visit: Full-body skin examination

S – Subjective:

Patient presents for annual total body skin examination. Reports noticing increased number of brown spots on trunk and extremities over past several years. States her mother had similar skin changes. Denies any rapidly growing, changing, or bleeding lesions. No personal history of skin cancer or atypical moles. Some lesions on back occasionally itch, particularly when dry in winter months. Uses moisturizer intermittently. No new lesions of concern. Patient has limited sun exposure now but reports significant recreational sun exposure in younger years including tanning bed use in her 30s. Applies sunscreen inconsistently.

O – Objective:

Vital Signs: Stable
Comprehensive Skin Examination:

• Face: 4-5 small (2-4mm) tan to brown flat to slightly raised papules on bilateral cheeks and forehead, stuck-on appearance, consistent with seborrheic keratoses. Multiple lentigines noted.
• Scalp: No suspicious lesions on scalp survey.
• Trunk (anterior): 12-15 seborrheic keratoses ranging 4-12mm on chest and abdomen, brown to dark brown, well-demarcated, waxy surface, stuck-on appearance. Dermoscopy performed on largest lesion (12mm, right chest): demonstrates horn cysts, comedo-like openings, and cerebriform pattern consistent with seborrheic keratosis.
• Trunk (posterior): Numerous seborrheic keratoses, estimated 20+, ranging 3-10mm, similar morphology. One lesion on right scapular region, 7mm, slightly more pigmented with mild surrounding erythema (patient reports scratching due to itch).
• Upper extremities: Scattered seborrheic keratoses bilaterally, 5-8 per arm, 3-6mm, typical appearance. Solar lentigines on bilateral dorsal hands and forearms.
• Lower extremities: Few seborrheic keratoses on bilateral thighs, 3-5mm. No lesions on lower legs or feet.
• No atypical nevi identified. No lesions suspicious for basal cell carcinoma, squamous cell carcinoma, or melanoma visualized on today's examination.

A – Assessment:

Multiple seborrheic keratoses on face, trunk, and extremities, clinically typical, benign appearance. Sign of Leser-Trélat not evident (no sudden eruption associated with internal malignancy). Patient demonstrates normal age-related increase in seborrheic keratoses. Mild irritation on right scapular lesion due to mechanical trauma from scratching, no signs of infection or malignant transformation. No suspicious pigmented or non-pigmented lesions identified. Patient at moderate risk for skin cancer given fair skin, history of significant sun exposure, and tanning bed use.

P – Plan:

Lesion Management: Discussed benign nature of seborrheic keratoses. Explained these are extremely common, age-related growths with no malignant potential. No treatment required unless lesions become symptomatic, irritated, or patient desires removal for cosmetic reasons. For irritated lesion on right scapular area, recommended applying moisturizer twice daily and avoiding scratching. If continues to be problematic, can perform cryotherapy or shave removal at future visit.

Skin Cancer Prevention: Counseled extensively on sun protection including daily broad-spectrum SPF 30+ sunscreen, protective clothing, wide-brimmed hat, and avoiding peak sun hours 10am-4pm. Emphasized importance given personal history of significant UV exposure. Provided written sun safety information.

Monitoring: Instructed patient on ABCDEs of melanoma detection (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolving). Emphasized seborrheic keratoses do not transform into skin cancer, but patient should monitor all skin lesions for changes. Encouraged monthly self-skin examinations and having spouse check back areas.

Follow-up: Recommended annual full-body skin examinations given risk factors. Patient to contact office sooner if develops any new rapidly growing lesions, bleeding lesions, non-healing sores, or changing moles. Patient expressed relief regarding benign nature of current lesions and verbalized understanding of monitoring plan and sun protection recommendations.

Example 3: Irritated Seborrheic Keratosis, Rule Out Malignancy

Patient: 72-year-old male
Chief Complaint: "Bleeding mole on my back"
Visit: Evaluation of bleeding skin lesion

S – Subjective:

Patient reports lesion on mid-back that has been present for many years, possibly decades. States he has multiple similar spots on his body that have never caused problems. This particular lesion began bleeding 3 days ago after his wife accidentally scratched it with her fingernail. Bleeding stopped with pressure but has developed a crust. Now concerned because he read that bleeding moles can be cancer. Denies pain from the lesion currently. No fever, increasing redness, or signs of infection. No other skin lesions of concern. Personal history of basal cell carcinoma removed from nose 5 years ago with clear margins. Takes aspirin 81mg daily for cardiac prophylaxis. No family history of melanoma.

O – Objective:

Vital Signs: BP 132/78, otherwise stable
Focused Skin Examination:

• Mid-back, right paraspinal region: 11mm x 9mm brown to dark brown, exophytic papule with verrucous, stuck-on appearance. Central crust approximately 4mm with small amount of dried blood, no active bleeding. Base appears well-circumscribed. Surrounding skin without erythema, warmth, or induration. No satellite lesions.
• Dermoscopy: Multiple milia-like cysts and fissures visible. Central area obscured by crust but no atypical vascular structures visible at periphery. Dermoscopic features at lesion periphery consistent with seborrheic keratosis including comedo-like openings and fingerprint pattern. No blue-white veil, irregular dots/globules, or atypical pigment network.
• Remainder of back: Multiple additional seborrheic keratoses noted, ranging 5-15mm, various shades of brown, typical stuck-on appearance, none with concerning features.
• Total body skin scan: No suspicious melanocytic lesions identified. Well-healed scar on nasal sidewall from previous basal cell carcinoma removal.

A – Assessment:

Traumatized seborrheic keratosis, mid-back, with superficial erosion and crust formation. Clinical and dermoscopic features strongly favor benign seborrheic keratosis with mechanical trauma causing bleeding episode. However, given trauma obscures complete dermoscopic evaluation, history of bleeding, patient anxiety regarding potential malignancy, and history of prior non-melanoma skin cancer, biopsy recommended to definitively rule out atypical lesion or concurrent skin cancer.

P – Plan:

Diagnostic Approach: Discussed findings with patient and explained that clinical appearance strongly suggests benign seborrheic keratosis with traumatic injury. However, given the crusting prevents full dermoscopic evaluation and patient's concern about malignancy, recommend shave removal biopsy for histologic diagnosis and to definitively rule out any atypical features or skin cancer. Patient agreed to proceed.

Procedure: Obtained informed consent after discussing risks including bleeding, infection, scarring, and need for further treatment if pathology reveals unexpected findings. Area cleansed with chlorhexidine. 1% lidocaine without epinephrine infiltrated given patient on aspirin (not discontinued for minor procedure). Tangential shave excision performed, removing entire lesion to dermis level. Hemostasis achieved with Monsel's solution and pressure. Specimen submitted in formalin for histopathologic examination. Wound dressed with antibiotic ointment and bandage.

Post-Procedure Instructions: Keep wound clean and dry for 24 hours. Apply antibiotic ointment twice daily and cover with bandage until re-epithelialized, approximately 10-14 days. Expect pink scar that fades over several months. Contact office for signs of infection. May resume normal activities, avoid submersion in pool/bath for 48 hours, showering acceptable after 24 hours.

Results and Follow-up: Pathology results expected in 7-10 days. Office will contact patient with results. If confirms benign seborrheic keratosis as expected, no further treatment needed. If pathology reveals dysplasia or malignancy, patient will be scheduled for appropriate further management. Given history of basal cell carcinoma, recommended annual skin examinations. Discussed sun protection and self-monitoring. Patient verbalized understanding and expressed relief that lesion will be definitively diagnosed.

Example 4: Sign of Leser-Trélat Evaluation

Patient: 54-year-old female
Chief Complaint: Sudden appearance of multiple skin growths over 3 months
Visit: Dermatology evaluation for eruptive seborrheic keratoses

S – Subjective:

Patient reports rapid development of numerous brown, raised bumps on trunk and back over past 3 months. States she has had occasional similar spots for years but recently noticed many new ones appearing. Describes itching associated with lesions, particularly on back. Also reports unintentional 15-pound weight loss over same time period and decreased appetite. Has felt more fatigued recently but attributed to work stress. Denies night sweats. No fever. No personal history of skin cancer. Occasional sun exposure. No tanning bed use. Medical history includes hypertension, controlled on medication. Last colonoscopy at age 50 was normal. Has not had routine mammogram in 3 years. No recent physical examination.

O – Objective:

Vital Signs: BP 128/82, HR 88, Wt 142 lbs (down from 157 lbs per patient report 3 months ago), Temperature 98.4°F
General: Appears mildly anxious, no acute distress
Full Body Skin Examination:

• Face and scalp: Few scattered seborrheic keratoses, 3-5mm, long-standing per patient
• Trunk (anterior and posterior): Numerous seborrheic keratoses, estimated 40+, predominantly on back, chest, and upper abdomen. Lesions range 4-12mm, brown to dark brown, verrucous surface, stuck-on appearance. Many appear similar in size and development stage. Some with surrounding erythema. No ulceration or bleeding.
• Upper extremities: Multiple seborrheic keratoses, approximately 15-20 total, 3-8mm
• Lower extremities: Scattered seborrheic keratoses, fewer than upper body
• Dermoscopy performed on multiple representative lesions: Findings consistent with seborrheic keratoses including horn cysts, comedo-like openings, cerebriform pattern. No atypical features.
• Abdominal exam: Soft, non-tender, no palpable masses, normal bowel sounds

A – Assessment:

Eruptive seborrheic keratoses concerning for possible Sign of Leser-Trélat. This represents sudden appearance of multiple seborrheic keratoses potentially associated with internal malignancy, most commonly gastrointestinal adenocarcinoma. Patient's concurrent unintentional weight loss and constitutional symptoms raise significant concern for underlying malignancy. While eruptive seborrheic keratoses can occasionally occur without malignancy (inflammatory dermatoses, medication reactions, pregnancy), the constellation of rapid onset, extensive distribution, and systemic symptoms warrants thorough evaluation. Differential diagnosis includes paraneoplastic process, inflammatory dermatosis, or benign eruptive seborrheic keratoses without associated malignancy.

P – Plan:

Urgent Internal Medicine Referral: Discussed concerning features with patient including sudden eruptive nature of lesions, weight loss, and constitutional symptoms. Explained Sign of Leser-Trélat and its association with internal malignancy. Emphasized importance of prompt evaluation by primary care physician or internist for comprehensive cancer screening. Placed urgent referral to patient's PCP with detailed note including concerns. Recommended evaluation should include comprehensive metabolic panel, CBC, chest X-ray, age-appropriate cancer screening including updated colonoscopy and mammogram given gaps in screening, consideration of CT chest/abdomen/pelvis based on clinical judgment.

Dermatology Management: Lesions themselves are benign and do not require removal unless symptomatic. For itching, recommended gentle skin care with fragrance-free moisturizer twice daily, avoiding hot showers, and can use OTC hydrocortisone 1% cream to pruritic areas twice daily for symptomatic relief. If specific lesions become irritated or bothersome, can perform cryotherapy at follow-up visit.

Documentation: Photographed representative lesions with patient consent for medical record documentation and comparison at future visits.

Follow-up Plan: Patient to follow up with PCP within 1 week for systemic evaluation. Patient to return to dermatology after completion of internal workup or in 3 months, whichever occurs first. Earlier follow-up if lesions change dramatically, become symptomatic, or any suspicious lesions develop. Provided patient with written information about Sign of Leser-Trélat. Patient contact information verified and after-hours number provided.

Communication: Will contact patient in 1 week to ensure she has been evaluated by PCP and workup has been initiated. Emphasized importance of not delaying evaluation. Patient appeared appropriately concerned and committed to prompt follow-up. Patient verbalized understanding of recommendations and agreed to complete cancer screening promptly.

Key Components Insurance Companies Look For in Seborrheic Keratosis SOAP Notes

When reviewing your dermatology documentation, insurance companies specifically want to see:

1. Detailed Lesion Description

Size (measured in millimeters), location (anatomically specific), color, morphology, surface characteristics, and borders. This distinguishes a thorough evaluation from a cursory one.

2. Dermoscopic Findings

Document use of dermoscopy and specific findings such as horn cysts, comedo-like openings, fingerprint pattern, or fissures. This demonstrates appropriate diagnostic technique and supports clinical diagnosis.

3. Differential Diagnosis

Show clinical reasoning by noting what else was considered. For pigmented lesions, document why melanoma, dysplastic nevus, or other concerning diagnoses were excluded.

4. Medical Necessity for Treatment

If removing a lesion, document justification: symptoms (pain, itching, bleeding), mechanical irritation, cosmetic concerns affecting quality of life, or diagnostic uncertainty requiring biopsy.

5. Photographic Documentation

When available, reference clinical photography and dermoscopy images. This supports diagnosis and provides baseline for comparison.

6. Patient Education

Document counseling about benign nature, malignant transformation risk (none), treatment options, and surveillance recommendations.

Common Mistakes to Avoid

Vague Lesion Descriptions: Instead of "brown spot on back," document "8mm x 6mm brown papule with verrucous surface, right scapular region, stuck-on appearance."

Skipping Dermoscopy: If you have a dermoscope, use it and document findings. It demonstrates thoroughness and supports your diagnosis.

No Differential Diagnosis: Don't just state seborrheic keratosis. Mention you considered and ruled out melanoma, pigmented basal cell carcinoma, or solar lentigo based on clinical features.

Inadequate Justification for Removal: "Patient requested removal" isn't sufficient for insurance. Document specific symptoms, irritation, diagnostic uncertainty, or quality of life impact.

Missing Risk Assessment: For patients with concerning features (rapid onset, multiple lesions, systemic symptoms), document consideration of Sign of Leser-Trélat and appropriate workup.

No Follow-up Plan: Always document recommended surveillance interval and circumstances requiring earlier return.

When to Biopsy vs. Observe

Clear documentation of decision-making helps defend your clinical judgment:

Consider Biopsy When:

• Atypical dermoscopic features present
• Recent trauma obscures full evaluation
• Rapid growth or change reported
• Bleeding without clear traumatic cause
• Patient with history of melanoma and diagnostic uncertainty
• Lesion on acral site with atypical features
• Patient anxiety preventing acceptance of clinical diagnosis

Observation Appropriate When:

• Classic clinical appearance with typical dermoscopic features
• Stable lesion over time
• Multiple similar lesions in same patient
• Patient comfortable with diagnosis and monitoring
• No symptoms requiring intervention

Always document your clinical reasoning for either approach.

Final Thoughts

Seborrheic keratosis SOAP notes don't need to be overwhelming.

They need to be thorough enough to demonstrate appropriate clinical evaluation and sound decision-making.

The key is having a system that captures essential clinical details without making you feel like you're spending more time documenting than examining patients.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that serves your patient, protects you from liability, and satisfies insurance requirements.

Your time is better spent caring for patients than fighting with documentation.

That's exactly why we built this tool.

Try it out, see how much time you get back, and let me know what you think.

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