SOAP note example: atopic dermatitis

Eczema notes are often vague: "eczema flare, steroid cream". A reader cannot tell the extent, the potency used where, or how much the child's sleep is affected. The invented notes below describe a flare in a child and an infected flare, followed by what each SOAP section should say about skin, treatment and infection.

Example: eczema flare in a child

S: 6-year-old boy with eczema since infancy, flare for 2 weeks affecting elbows, knees and neck. Itch waking him 3 to 4 nights a week. Mother applies emollient once a day, less than one 500 g tub a month. Uses hydrocortisone 1% from a previous visit, occasionally. No weeping, crusting or pain. No fever. Mild hay fever. No food reactions. School reports scratching in class.
O: Well child. Weight 21 kg. Dry skin generally. Erythematous, lichenified plaques with excoriation in both antecubital and popliteal fossae and on the anterior neck. About 8% body surface area. No crusting, pustules or punched-out erosions. POEM score 16.
A: Atopic dermatitis, moderate flare. No signs of infection.
P: 1. Emollient at least twice daily and after bathing, used as soap substitute; about 250 to 500 g a week.
2. Clobetasone butyrate 0.05% once daily to limbs for 7 days, then twice weekly to usual flare sites for 4 weeks.
3. Hydrocortisone 1% once daily to neck for up to 7 days.
4. Fingertip unit amounts explained and shown.
5. Cotton clothing, short nails.
6. Return urgently for painful, spreading sores, blisters or fever.
7. Review in 4 weeks.

What each SOAP section needs for eczema

• Subjective: duration of the flare, sites, itch and sleep disturbance (nights per week), current emollient type and amount actually used, steroid creams with potency and how often, triggers such as soaps, heat, sweat or pets, signs of infection noticed at home, and the effect on school, work or mood. Other atopic conditions are worth one line.
• Objective: distribution, morphology (erythema, lichenification, excoriation, oozing), an estimate of body surface area or a severity score, and a specific statement on infection: crusting, weeping, pustules, or punched-out erosions and vesicles that suggest eczema herpeticum. Growth in children if relevant.
• Assessment: severity of the flare and whether it is infected.
• Plan: emollient with quantity, each topical steroid with potency, site, frequency and duration, step-down or weekend therapy, fingertip-unit teaching, infection advice and review date.

Potency matters more than brand. Writing the potency class next to a product name helps any reader judge whether the plan fits the site treated.

Example: infected eczema

S: 9-year-old girl with eczema, 4 days of weeping and golden crusts on both wrists. Itchy and sore. Temperature normal at home. No blisters.
O: Well. Temp 36.8. Honey-colored crusting and weeping over both wrist flexures, about 3% body surface area. No punched-out erosions, no clustered vesicles.
A: Atopic dermatitis with localized secondary bacterial infection. No features of eczema herpeticum.
P: Oral flucloxacillin, weight-based dose, 5 days. Continue topical steroid to affected areas. New emollient pots to avoid contamination. Same-day return for fever, rapidly spreading sores or blisters.

Common gaps in eczema documentation

• Steroid named without potency, site or duration.
• Emollient advice with no quantity.
• No statement on infection, and particularly no mention that eczema herpeticum was considered.
• Extent described as "widespread" without a percentage or score.
• Sleep and school effects left out, though they drive treatment intensity.

ICD-10 codes for atopic dermatitis

For infected eczema, some coders prefer the atopic dermatitis code plus a code for the infection. Follow your service's convention.

Eczema notes drafted by ClearPass

A lot of eczema consultation time goes into explaining creams. With Transcribe on, after the parent or patient agrees, ClearPass keeps that explanation and turns it into a SOAP draft whose plan names each product, site, frequency and duration you said. The skin description you dictate while examining goes to O.

If you photograph an old clinic letter or a lab result, photo upload reads its clinical details into the note; remove identifiers first. Numbers not said in the transcript, such as a body surface area or a cream quantity, are marked by the numbers check. Patient instructions, often the most useful output for eczema, are one click, as are ICD-10 codes and a dermatology referral. Review before use.

What ClearPass does not do

• It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
• It is not a medical device and does not make clinical decisions. It is a documentation aid.
• It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

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