Dermatology Note: Structure and Sections
Dermatology visit note with lesion morphology and distribution. Notermed's built-in Dermatology Note produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record.
What the Dermatology Note contains
11 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Chief Complaint
- The primary skin concern, as stated
- 2
History of Present Illness
- Onset, duration, and the sites involved
- How the lesions have changed over time
- Pruritus, pain, bleeding
- Triggers or exposures: new products, sun, occupation
- Prior treatments tried and the response
- Sun-protection habits, where discussed
- 3
Past Medical History
- Prior skin cancers
- Atopy: eczema, asthma, allergic rhinitis
- Autoimmune disease or immunosuppression
- Surgeries
- 4
Medications
- Topical and systemic medications
- Dose, frequency, and duration
- 5
Allergies
- Drug and contact allergies, and the reactions
- 6
Social History
- Sun exposure and tanning history
- Occupation, smoking, relevant hobbies
- 7
Family History
- Melanoma, non-melanoma skin cancer, psoriasis, atopy
- 8
Skin Examination
- Lesion by lesion, exactly as described
- Site, morphology, size, color, borders
- Distribution, recorded as the sites actually stated
- Dermoscopic findings, where verbalized
- 9
Results
- Pathology and laboratory results
- The report diagnosis line kept as written
- Biopsy pathology, KOH prep, culture, patch test results
- 10
Assessment
- The impression the clinician stated, per lesion or per problem
- A differential, only where one was verbalized
- 11
Plan
- Biopsies or procedures performed or scheduled
- Prescriptions with strength and instructions as stated
- Wound care instructions as stated
- Sun-protection counseling, where actually given
- Follow-up interval and referrals
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
Questions about the Dermatology Note
What sections does the dermatology note contain?
Eleven: Chief Complaint, History of Present Illness, Past Medical History, Medications, Allergies, Social History, Family History, Skin Examination, Results, Assessment and Plan.
How are the lesions described?
Lesion by lesion, exactly as described: site, morphology, size, color, borders, and the distribution recorded as the sites actually stated, with dermoscopic findings where they were verbalized.
Does the note record pathology results?
Where they were reviewed. Results carries pathology and laboratory results with the report diagnosis line kept as written, including biopsy pathology, a KOH prep, culture and patch test results.
What happens to advice that was never given?
It does not appear. The plan records what was actually said, and a section nobody said anything about is left out of the draft rather than padded.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the Dermatology Note on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.