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Note formats · Dermatology

Dermatology Note Template With Lesion Exam

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.

Dermatology Note
Sections
11, in the note's own order
Specialty
Dermatology
Unsaid sections
Left out, never padded
Structure reviewed

In order

Chief Complaint · History of Present Illness · Past Medical History · Medications · Allergies · Social History · Family History · Skin Examination · Results · Assessment · Plan

What the Dermatology Note contains

11 sections

11 sections, in the order the note puts them, and what each one takes from the visit.

  1. 1

    Chief Complaint

    • The primary skin concern, as stated
  2. 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. 3

    Past Medical History

    • Prior skin cancers
    • Atopy: eczema, asthma, allergic rhinitis
    • Autoimmune disease or immunosuppression
    • Surgeries
  4. 4

    Medications

    • Topical and systemic medications
    • Dose, frequency, and duration
  5. 5

    Allergies

    • Drug and contact allergies, and the reactions
  6. 6

    Social History

    • Sun exposure and tanning history
    • Occupation, smoking, relevant hobbies
  7. 7

    Family History

    • Melanoma, non-melanoma skin cancer, psoriasis, atopy
  8. 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. 9

    Results

    • Pathology and laboratory results
    • The report diagnosis line kept as written
    • Biopsy pathology, KOH prep, culture, patch test results
  10. 10

    Assessment

    • The impression the clinician stated, per lesion or per problem
    • A differential, only where one was verbalized
  11. 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

Nothing padded

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.

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.

Questions about the Dermatology Note

4 questions
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.

Other formats

3 formats

This format is the built-in dermatology format. See the AI scribe for dermatology clinics.

All 21 built-in note formats

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 used for training

    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.

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.

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