Complete Guide to Seborrheic Keratosis SOAP Note Examples for Healthcare Providers

If you've ever needed to document seborrheic keratosis evaluations efficiently while ensuring proper coding and billing, this guide is for you.

I've talked to countless dermatologists, family physicians, and primary care providers who see these benign lesions daily and need streamlined documentation that distinguishes them from concerning skin findings.

The reality is that seborrheic keratosis documentation needs to be clear enough to justify cosmetic versus medical treatment, support proper billing, and rule out malignancy.

Insurance companies want to see detailed descriptions that differentiate these benign lesions from melanoma or other skin cancers, especially when removal is considered medically necessary.

That's exactly why I built SOAP Notes Doctor to handle documentation efficiently while you focus on patient care and accurate diagnosis.

In this article, I'll show you exactly how to write seborrheic keratosis SOAP notes that meet documentation standards, with practical examples you can adapt.

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

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

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 seborrheic keratosis specifically, SOAP notes are critical because they demonstrate:

• Clear differentiation from malignant lesions
• Appropriate clinical assessment and dermoscopy findings when applicable
• Medical necessity for removal versus cosmetic concerns
• Patient education about benign nature of lesions
• Follow-up plans for monitoring or treatment

SOAP stands for:

• S — Subjective: What the patient reports about the lesion: when noticed, growth changes, symptoms (itching, bleeding, irritation), cosmetic concerns, or family history.
• O — Objective: Your clinical findings including lesion location, size, color, borders, surface characteristics, number of lesions, and dermoscopy findings if performed.
• A — Assessment: Your clinical diagnosis of seborrheic keratosis with confidence level, differential diagnoses considered, and risk assessment.
• P — Plan: Your treatment plan including observation, cryotherapy, shave removal, patient education about benign nature, and follow-up recommendations.

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

You're not just recording what you saw—you're building a clinical record that justifies your diagnosis and treatment decisions.

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 section after examining the patient. It works if you see a manageable number of patients and have time for detailed documentation. The challenge is when you're seeing 30+ patients daily with multiple skin lesions each, manual documentation becomes overwhelming.

2. SOAP Notes Doctor

You record your examination findings or dictate your observations, and the tool automatically structures everything into proper SOAP format. It maintains consistency, saves significant time when documenting multiple lesions, and ensures you capture all necessary details for billing and medical-legal protection.

How to Make Seborrheic Keratosis SOAP Notes Faster

One of the biggest complaints I hear from dermatologists and primary care providers is how documenting multiple skin lesions eats into their limited time.

You've just finished a full day of skin checks, each patient with 5-10 different lesions requiring documentation, and instead of finishing on time, you're stuck describing each seborrheic keratosis in detail.

The pressure is real: make them too brief and you risk billing issues or missing a concerning lesion; 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
✅ Document multiple lesions efficiently

With soapnotes.doctor, you can record during examination, add rough notes about specific findings, or even upload audio later. The system converts everything into proper SOAP notes automatically.

You still get the clinical accuracy and thoroughness needed for good documentation, but without manually typing every detail.

Maybe you noted specific findings?

"Left temple, 8mm, brown, stuck-on appearance, well-demarcated, waxy surface,horn cysts visible, 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 Concern

Patient: 58-year-old female
Chief Complaint: "Growth on my face that I want removed"
Visit: Dermatology consultation

S – Subjective:

Patient reports noticing a brown spot on her left cheek approximately 2 years ago. States it has gradually grown larger and become more raised. Denies any pain, bleeding, or itching. Primary concern is cosmetic appearance. No recent changes in color or texture. No family history of skin cancer. Patient works outdoors as a landscaper with history of sun exposure. Denies previous skin cancer diagnoses.

O – Objective:

Skin Exam: Single well-demarcated lesion on left cheek, measuring 9mm x 8mm. Brown pigmentation with "stuck-on" waxy appearance. Surface shows multiple horn cysts and fissures. Borders sharply demarcated. No erythema, ulceration, or bleeding. Surrounding skin shows moderate solar damage with scattered lentigines. Dermoscopy: Multiple milia-like cysts, comedo-like openings, fingerprint-like structures. No atypical vascular patterns, blue-white structures, or irregular pigment network.

A – Assessment:

Seborrheic keratosis, left cheek. Benign lesion with classic clinical and dermoscopic features. No concerning features for malignancy. Patient requesting removal for cosmetic reasons.

P – Plan:

Discussed benign nature of seborrheic keratosis with patient. Explained that these are common age-related growths that are not cancerous and do not require removal unless symptomatic or for cosmetic concerns. Patient elected for removal due to cosmetic preference. Performed shave removal with light electrodesiccation to base. Lesion sent to pathology for routine histologic confirmation. Wound care instructions provided including antibiotic ointment and bandaging. Patient instructed on signs of infection. Discussed sun protection given occupational exposure and solar damage. Follow-up PRN or if pathology shows unexpected findings. Patient verbalized understanding.

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Example 2: Multiple Seborrheic Keratoses, Routine Skin Check

Patient: 65-year-old male
Chief Complaint: Annual skin check
Visit: Full body skin examination

S – Subjective:

Patient presents for routine annual skin examination. Reports noticing several "brown spots" on his back and chest over the past few years. States some occasionally catch on clothing causing mild irritation. Denies rapid growth, color changes, bleeding, or pain. Personal history of one basal cell carcinoma removed from nose 3 years ago. Family history significant for father with melanoma. No current skin concerns beyond the "barnacles" on his torso.

O – Objective:

General Skin Exam: Skin type II, multiple solar lentigines across sun-exposed areas. Trunk: Approximately 15-20 seborrheic keratoses scattered across upper back and chest, ranging 4-12mm in size. All with classic stuck-on appearance, brown to tan coloration, well-demarcated borders, waxy surface texture with visible horn cysts. Back (mid-scapular region): Three larger seborrheic keratoses (10-12mm) showing mild irritation at base from clothing friction. No ulceration. Remainder of examination: No suspicious lesions identified. Previous BCC scar on nose well-healed.

A – Assessment:

Multiple seborrheic keratoses, trunk—benign. Mild irritation from clothing friction on three larger lesions. History of basal cell carcinoma, currently no evidence of recurrence. No suspicious lesions requiring biopsy at this time.

P – Plan:

Reassured patient regarding benign nature of seborrheic keratoses. Discussed that these are extremely common age-related growths. For the three irritated lesions, offered cryotherapy to reduce size and irritation. Performed liquid nitrogen cryotherapy to three symptomatic lesions on back. Explained that treated areas will blister, darken, and gradually slough off over 2-4 weeks. Reviewed warning signs of skin cancer and importance of monitoring for changing lesions. Recommended annual full-body skin examinations given personal and family history. Patient to return in one year for routine follow-up or sooner if new concerning lesions develop.

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Example 3: Inflamed Seborrheic Keratosis, Concern for Malignancy

Patient: 52-year-old female
Chief Complaint: "Mole on my back changed and started bleeding"
Visit: Urgent dermatology visit

S – Subjective:

Patient reports a lesion on her upper back that she's had for "many years" recently became irritated. States it started itching about 2 weeks ago, and she scratched it causing bleeding 3 days ago. Concerned because she's read that bleeding moles can be cancer. Denies intentional trauma before scratching. Lesion previously was "just a brown bump" that didn't bother her. No pain currently. No fever or systemic symptoms. Personal history of numerous benign moles removed in the past.

O – Objective:

Right upper back: 11mm lesion with stuck-on appearance and verrucous surface consistent with seborrheic keratosis. Central area shows crust from recent bleeding with surrounding erythema and mild inflammation. Peripheral portion shows classic brown pigmentation with horn cysts. No significant asymmetry or irregular borders. Small amount of dried blood visible on surface. Dermoscopy: Crust obscuring central area, peripheral areas show milia-like cysts and comedo-like openings consistent with seborrheic keratosis. No atypical network or irregular vessels in visible areas.

A – Assessment:

Inflamed seborrheic keratosis, right upper back, secondary to trauma/scratching. Clinical appearance consistent with benign lesion, however cannot completely exclude melanoma given inflammation obscuring features and patient history of bleeding. Biopsy warranted for definitive diagnosis and patient reassurance.

P – Plan:

Explained to patient that lesion has classic appearance of seborrheic keratosis, which is benign, and inflammation likely from scratching. However, given concern for bleeding and inability to fully visualize all features due to inflammation, recommended shave biopsy for histologic diagnosis to definitively rule out melanoma. Patient agreed. Performed shave biopsy with submission to pathology. Hemostasis achieved with aluminum chloride. Wound care instructions provided. Patient will be contacted with pathology results in 5-7 days. Discussed that seborrheic keratoses can become inflamed when irritated but this doesn't indicate cancer. Instructed to avoid scratching and monitor other lesions. Follow-up scheduled in 2 weeks for pathology review and wound check. Patient reassured and verbalized understanding.

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Key Components Insurance Companies Look For in Seborrheic Keratosis SOAP Notes

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

1. Detailed Lesion Description

Location, size, color, borders, surface characteristics, and number of lesions. This supports your diagnosis and billing codes.

2. Differentiation from Malignancy

Document why you believe the lesion is benign. Mention features that rule out melanoma, basal cell carcinoma, or squamous cell carcinoma.

3. Medical Necessity for Treatment

If removing or treating, document symptoms (itching, bleeding, irritation, trauma) or diagnostic uncertainty. Pure cosmetic removal may not be covered.

4. Dermoscopy Findings When Applicable

Dermoscopic features strengthen diagnostic confidence and support decision-making for observation versus biopsy.

5. Patient Concerns and Education

Document patient's specific concerns and education provided about benign nature, especially when declining treatment.

6. Histopathology Correlation

When biopsied or removed, document clinical impression and note whether pathology confirmed diagnosis.

Common Mistakes to Avoid

Vague Lesion Descriptions: Instead of "brown spot," document specific features: "10mm brown plaque with stuck-on appearance, waxy surface, and multiple horn cysts."

Missing Medical Necessity Documentation: If treating, document symptoms or diagnostic uncertainty. "Patient requests removal" isn't sufficient for insurance.

Not Considering Differential Diagnosis: Document what else you considered (melanoma, lentigo, nevus) and why you diagnosed seborrheic keratosis.

Inadequate Size Documentation: Always measure and document lesion size. "Small" or "large" doesn't support billing codes.

Forgetting Patient Education: Document that you explained benign nature, especially when patient was concerned about cancer.

No Photodocumentation Reference: When photographs are taken, note this in the chart for future comparison.

Tips for Efficient Documentation

Use Templates for Common Presentations: Create templates for single lesion versus multiple lesions, cosmetic versus symptomatic removal.

Standardize Your Descriptive Terms: Develop consistent language for describing classic features (stuck-on, waxy, horn cysts, fissures).

Document Decision-Making: Briefly note why you chose observation versus treatment versus biopsy based on clinical features.

Batch Similar Lesions: When documenting multiple seborrheic keratoses, you can group similar lesions by location with size ranges.

Include Dermoscopy Findings: Even brief dermoscopy notes ("classic SK features on dermoscopy") strengthen documentation.

Final Thoughts

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

They need to be accurate, yes, but they don't need to consume excessive time when you're seeing multiple patients with multiple lesions.

The key is having a system that captures essential diagnostic features without making documentation feel burdensome.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that supports your clinical diagnosis and treatment decisions.

Your time is better spent examining patients and providing care than typing repetitive lesion descriptions.

That's exactly why we built this tool.

Try it out, see how much time you save on dermatology documentation, and let me know what you think.

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Visit soapnotes.doctor and get your first notes generated in minutes.