The Right Way to Write SOAP Notes for Rash

When I first started shadowing clinicians, I noticed something: everyone got a little tense when it was time to document rashes.

Was it hives or contact dermatitis? Was there a pattern worth noting? Did they remember to document the patient's own description?

These little details matter and they can make SOAP notes feel like detective work.

That's why I'm writing this.

Consider this your quick, founder-approved guide to writing a great SOAP note for a rash without overthinking it.

Quick tip: We built SOAP Notes doctor to assist medical professionals effortlessly write notes using industry best practices. Saves 90% of time.

SOAP Notes 101

Here's the thing about SOAP notes.

Back in the 1960s, Dr. Lawrence Weed came up with this format because documentation was messy and disorganized. The goal was simple: give every patient encounter a clear, repeatable structure that any clinician could follow.

And it worked.

SOAP notes break a visit into four parts:

• Subjective: the patient's words. What they're feeling, noticing, or worried about.
• Objective: the facts. What you can see, measure, or test.
• Assessment: your take. What you think is happening based on what you know.
• Plan: what happens next. Your roadmap for treatment or follow-up.

I also like to look at them like this…

Step	Action
Listen	(Subjective)
Look	(Objective)
Think	(Assessment)
Act	(Plan)

That's it. It's basically a storytelling framework for medicine.

Once you get used to it, you start to see how powerful it is for keeping care clear, organized, and easy to follow even when you're dealing with something as vague as a rash.

How to Approach SOAP Notes for Rash

Rashes are one of those complaints that seem simple on the surface but can take a turn toward complex very quickly. That's why a well-structured SOAP note can be a lifesaver.

The goal here is to document clearly enough that anyone reading your note — including future-you — understands what happened, what you saw, what you thought, and what you planned to do next.

Let's break this down step by step.

Subjective: Listen First, Capture the Story

Your first job is to let the patient talk.

This is where you get the "why" behind the visit.

Technically, the patients will often have very specific concerns: "It's itchy," "It's spreading," "I just got back from the park," or "I think it's an allergic reaction."

These details matter more than you might think because rashes are often a puzzle where timing, exposure, and symptom progression are key.

I always suggest asking open-ended questions first ("Tell me about when you first noticed this rash") before drilling down into specifics.

Once they share freely, document the onset (when it started), location (where it first appeared and where it is now), symptoms (itching, pain, burning, swelling), and any associated factors (fever, new medication, recent travel, new skincare products, bug bites, etc.).

If it's a child, get the caregiver's observation, rashes can look very different by the time they get to your office.

Good subjective documentation might read like:

"Patient reports an itchy red rash that appeared two days ago after gardening. Rash started on forearms, now on neck. Denies fever. Tried OTC hydrocortisone with mild relief."

What you're doing here is giving context.

If you only write "rash on forearm," you miss half the story.

Future-you or another provider will thank you for taking an extra 30 seconds to add symptom progression and what's been tried.

Quick Tip: Use SoapNotes.doctor to record these sessions. It'll do the work of writing the SOAP notes tailored to the specific case. All you have to do is iterate on what you've already gotten.

Objective: Describe, Don't Diagnose (Yet)

Here's where you become the narrator, not the detective.

The objective section is purely about what you see, measure, and observe.

With rashes, this can be the trickiest part, but it's also where a detailed note could be most important.

Document the appearance: color, shape, size, distribution, and pattern. Is it maculopapular, vesicular, scaly, blanching, crusted? Is it localized or generalized?

Are there systemic signs — fever, lymphadenopathy, swelling?

You can even describe the borders ("well-defined" vs "ill-defined") and texture ("raised," "rough," "smooth").

If you can, include vital signs (e.g fever) can change the way you interpret a rash dramatically.

Photographs (if allowed by your workflow) are also a game-changer and make follow-up comparisons much easier.

A solid objective section might say:

"Erythematous maculopapular rash present on forearms and anterior neck, scattered distribution, non-blanching, no vesicles noted. No mucosal involvement. No lymphadenopathy. Vitals WNL."

This level of detail may feel overkill in the moment, but it's critical for trending, communication, and even medicolegal protection.

Quick Tip: You can add these using the tailorr feature in soapnotes.doctor to get a well generated objective session.

Assessment: Put the Puzzle Together

Now it's time to think out loud but concisely.

Your assessment forms a diagnosis or differential diagnosis. If you're confident ("classic allergic contact dermatitis"), you can be specific.

If you're not sure, list the possibilities ("differential includes contact dermatitis, viral exanthem, drug eruption").

Here's my personal opinion: your assessment should never be just one word, unless you are 100% certain and this is a routine follow-up. A vague "rash" in the assessment section is not helpful.

Even writing "likely allergic dermatitis based on distribution and history" is better than a generic note.

It shows you thought through the case.

If it's a case where you want to flag something potentially serious (e.g., petechial rash with fever), make sure your assessment communicates the urgency.

That clarity can make a big difference if another provider reads your note later.

Quick tip: With proper context added in the tailorr feature, you should easily get this and plan properly generated on SoapNotes.doctor using industry best practices.

Plan: Close the Loop

Your plan is your action list.

It's where you demonstrate that you're not just observing but actively managing the situation.

Depending on the rash, your plan might include:

• Symptomatic treatment (topical steroids, antihistamines, soothing creams)
• Diagnostic tests (skin scraping, blood work, culture if infectious cause suspected)
• Education (avoid triggers, when to return if worse, red flags like swelling of lips/tongue)
• Follow-up (recheck in X days if not improving, sooner if worsening)
• Referral (to dermatology, allergy, or infectious disease if needed)

I recommend writing your plan in bullet points or short lines. This makes it easy to read later.

For example:

"Start OTC hydrocortisone cream BID x 5 days. Avoid suspected trigger (garden plants). Educated on signs of anaphylaxis. Return in 48 hrs if spreading or new systemic symptoms."

Example SOAP Note for Rash

Patient: 32-year-old female
Date: [Insert date]
Provider: [Your name initials]

S – Subjective:

Patient reports onset of an itchy red rash on both forearms 2 days ago after working in her backyard garden. Rash has since spread to the anterior neck. Describes rash as mildly itchy, denies pain or burning. Denies fever, chills, shortness of breath, or swelling of lips/tongue. No new medications or soaps reported. Tried OTC hydrocortisone cream with mild relief. No similar rash in the past.

O – Objective:

• General: Patient alert, in no acute distress.
• Vitals: T 98.6°F, HR 78 bpm, BP 118/76 mmHg, RR 16/min.
• Skin: Erythematous maculopapular rash scattered over dorsal forearms and anterior neck, well-demarcated borders, non-blanching, no vesicles, no drainage. No facial edema.
• Other: No lymphadenopathy. Lungs clear to auscultation.

A – Assessment:

Likely allergic contact dermatitis, most likely secondary to plant exposure during gardening. Differential diagnosis includes irritant contact dermatitis, viral exanthem (less likely given distribution and no systemic symptoms).

P – Plan:

1. Continue OTC 1% hydrocortisone cream BID x 5–7 days.
2. Start oral antihistamine (cetirizine 10 mg daily) for itching.
3. Advise patient to avoid gardening without gloves until resolved.
4. Educated patient on red flag symptoms: swelling of lips/tongue, fever, spreading rash, blistering.
5. Follow-up in 3–5 days if rash persists or worsens; sooner if systemic symptoms develop.

Example SOAP Note for Rash (Pediatric Case)

Patient: 4-year-old male
Date: [Insert date]
Provider: [Your name or initials]

S – Subjective:

Mother reports that the child developed a pink rash on his trunk and upper arms 1 day ago. Rash appeared shortly after fever broke (temperature was 102°F two days ago, now resolved). Rash is not itchy or painful. No vomiting, diarrhea, or cough. Child is eating and drinking normally today. No new foods, soaps, or medications. No sick contacts reported other than daycare attendance.

O – Objective:

• General: Active, playful child, no acute distress.
• Vitals: T 98.4°F, HR 90 bpm, RR 20/min.
• Skin: Diffuse erythematous maculopapular rash on trunk and proximal arms, non-blanching, non-vesicular, no crusting, no mucosal involvement.
• HEENT: No conjunctivitis, no oral lesions.
• Other: No lymphadenopathy, lungs clear, abdomen soft, non-tender.

A – Assessment:

Likely viral exanthem (roseola infantum) given history of fever that resolved before rash onset and current well-appearing status. Low concern for bacterial infection or drug reaction.

P – Plan:

1. Reassured caregiver that rash is consistent with benign post-viral exanthem and should resolve on its own within several days.
2. No treatment necessary other than supportive care (hydration, rest).
3. Education provided on warning signs: persistent fever, lethargy, difficulty breathing, worsening rash, or new symptoms.
4. Return if red flags develop or rash persists beyond one week.