SOAPNote: 4:a3f87b84-9ee7-4c47-aed0-1f8e293aa4a0:56992
| note_id | โ |
| mrn | 41090 |
| date | 2026-04-08 |
| session_date | โ |
| em_code | 99215 |
| char_count | 3110 |
| generator | claude-code-direct |
| generated_at | 2026-04-09T00:07:40.634000000+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 - Baruch, Dorian (MRN 41090) Date of Service: 2026-04-08 DOB: 05/23/1954 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 14 prior biopsy records on file. Prior melanoscan sessions: 5. 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): 7,575 Longitudinal scan sessions: 5 Dermoscopy images on file: 23 CNN Risk Stratification: Lesions with MEL score > 0.50: 10 Lesions with MEL score > 0.30: 89 Lesions with BCC score > 0.50: 98 Maximum MEL score: 0.9386 Maximum BCC score: 0.9131 Dermoscopy max MEL: 0.9261 High-Risk Regional Distribution: View C2: 127 spots, max MEL=0.9386, max BCC=0.8778 View D3: 169 spots, max MEL=0.8248, max BCC=0.4918 View G2: 190 spots, max MEL=0.6592, max BCC=0.5221 View L2: 123 spots, max MEL=0.5938, max BCC=0.8532 View F3: 244 spots, max MEL=0.5473, max BCC=0.7424 Pathology History (14 records): 2025-11-10: Right upper arm - Dx: 2025-11-10: - Dx: 2025-11-10: - Dx: 2025-11-10: - Dx: 2025-11-10: - Dx: 2025-11-10: - Dx: 2025-11-10: - Dx: 2025-10-28: right upper arm - 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. 10 lesions with CNN MEL > 0.50 warrant further evaluation. 3. L57.0 - Actinic keratosis screening. High BCC scores (98 lesions > 0.50) noted in multiple regions. Medical Necessity: Whole body photography (CPT 96904) is medically necessary for longitudinal change detection in patient with 7,575 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 10 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" } } |
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