SOAPNote: 4:a3f87b84-9ee7-4c47-aed0-1f8e293aa4a0:56986
| note_id | โ |
| mrn | 15847 |
| date | 2026-04-08 |
| session_date | โ |
| em_code | 99215 |
| char_count | 3108 |
| generator | claude-code-direct |
| generated_at | 2026-04-09T00:07:40.628000000+00:00 |
| icd10_codes | ["Z85.820 (Personal history of malignant melanoma of skin)", "D22.9 (Melanocytic nevi, unspecified)", "L57.0 (Actinic keratosis)", "Z85.828 (Personal history of other malignant neoplasm of skin)", "D48.5 (Neoplasm of uncertain behavior of skin)"] |
| cpt_codes | ["99215 (E/M level 5, established patient)", "96904 (Whole body integumentary photography)"] |
| mips_json | {"509": {"status": "MET", "evidence": "CSC scan = recurrence exam"}, "317": {"status": "PENDING", "evidence": "BP screening at visit"}, "357": {"status": "N/A", "evidence": "No dermatologic surgical procedure today"}, "374": {"status": "N/A", "evidence": "No open referral loop"}, "485": {"status": "N/A", "evidence": "No psoriasis diagnosis"}, "486": {"status": "N/A", "evidence": "No dermatitis diagnosis"}} |
| full_note | SOAP/MIPS NOTE - Magistro, Theresa (MRN 15847) Date of Service: 2026-04-08 DOB: 07/14/1945 Provider: Drugge, RJ MD Visit Type: Established Patient, Full Body Scan S: Patient presents for scheduled Melanoscan whole-body photography visit. Personal history of malignant melanoma - presenting for melanoma recurrence surveillance. Patient has 20 prior biopsy records on file. Prior melanoscan sessions: 6. No acute complaints reported at check-in. O: PHYSICAL EXAM Whole Body Integumentary Photography performed with Melanoscan multi-camera array. Total lesions detected (CNN classification): 6,056 Longitudinal scan sessions: 6 Dermoscopy images on file: 177 CNN Risk Stratification: Lesions with MEL score > 0.50: 24 Lesions with MEL score > 0.30: 91 Lesions with BCC score > 0.50: 31 Maximum MEL score: 0.8729 Maximum BCC score: 0.7731 Dermoscopy max MEL: 0.8752 High-Risk Regional Distribution: View J2: 338 spots, max MEL=0.8729, max BCC=0.6717 View B3: 65 spots, max MEL=0.6741, max BCC=0.5852 View D2: 341 spots, max MEL=0.6607, max BCC=0.5969 View E3: 67 spots, max MEL=0.6507, max BCC=0.222 View F3: 92 spots, max MEL=0.6211, max BCC=0.4835 Pathology History (20 records): 2025-04-03: - Dx: 2025-04-03: - Dx: 2025-04-03: Right medial ankle - Dx: 2025-04-03: - Dx: 2025-04-03: - Dx: 2025-04-03: - Dx: 2025-04-03: - Dx: 2024-07-01: right back - Dx: A: ASSESSMENT 1. Z85.820 - Personal history of malignant melanoma. Patient requires ongoing surveillance per MIPS 509. 2. D48.5 - Neoplasm of uncertain behavior of skin. 24 lesions with CNN MEL > 0.50 warrant further evaluation. 3. L57.0 - Actinic keratosis screening. High BCC scores (31 lesions > 0.50) noted in multiple regions. Medical Necessity: Whole body photography (CPT 96904) is medically necessary for longitudinal change detection in patient with 6,056 tracked lesions and personal melanoma history. P: PLAN 1. Melanoma recurrence surveillance - CSC scan completed. Next scan in 6 months per MIPS 509 protocol. 2. Review 24 high-MEL lesions with senior dermatologist for potential biopsy decision. 3. Patient education: Sun protection counseling, self-skin examination instruction. 4. Follow-up: 6 months for repeat Melanoscan. ICD-10: Z85.820 (Personal history of malignant melanoma of skin) D22.9 (Melanocytic nevi, unspecified) L57.0 (Actinic keratosis) Z85.828 (Personal history of other malignant neoplasm of skin) D48.5 (Neoplasm of uncertain behavior of skin) CPT: 99215 (E/M level 5, established patient) 96904 (Whole body integumentary photography) MIPS Report: { "509": { "status": "MET", "evidence": "CSC scan = recurrence exam" }, "317": { "status": "PENDING", "evidence": "BP screening at visit" }, "357": { "status": "N/A", "evidence": "No dermatologic surgical procedure today" }, "374": { "status": "N/A", "evidence": "No open referral loop" }, "485": { "status": "N/A", "evidence": "No psoriasis diagnosis" }, "486": { "status": "N/A", "evidence": "No dermatitis diagnosis" } } |
๐ FileMaker: Notes1 (matches on mrn=15847)
Open FM:Notes1 record โ
FM field: Number