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Skin Specialist
30-45 minutes

Review of Skin Lesions in Dermatology Template

The s10.ai Dermatology Skin Lesion Review template is expertly crafted for dermatologists to meticulously document skin lesion assessments. This template enables detailed recording of diagnoses, treatment histories, and clinical observations, ensuring a comprehensive evaluation of the patient's dermatological condition. It is especially beneficial for documenting skin lesions that may necessitate further investigation or procedures, such as biopsies or excisions. By facilitating the creation of structured and informative notes, this template enhances communication with referring general practitioners and ensures seamless continuity of care. Perfect for dermatology clinics, the template optimizes the documentation process within s10.ai, encouraging clinicians to adopt and explore its capabilities.

4,637 uses
4.9/5.0
D
Dr. Michael Thompson
Template Structure

Organized sections for comprehensive clinical documentation

Dear GP [GP’s Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.),
(You must always write in full sentences and without bullet points for the below)
Diagnosis: [e.g., Seborrheic keratosis, dermatofibroma, basal cell carcinoma] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Treatment History: [Previous treatments or interventions, if any] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Past Medical History: [Relevant medical conditions, any intra cardiac device or pacemaker] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Drug History: [Current medications, any anticoagulants] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Allergy History: [Document any known allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Social History: [Relevant lifestyle factors, e.g., sun exposure, occupation, Fitzpatrick skin type, WHO performance status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Clinical Findings:
[Patient’s Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.), a [age]-year-old [male/female] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.), was reviewed in the dermatology clinic today regarding a [describe history of lesion: e.g., onset, growth] associated symptoms such as bleeding, pain, or rapid change (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) lesion on the [body site] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.).
On examination, the lesion is [describe lesion: e.g., patch, plaque, mole, size, color, texture, and any dermatoscopic features] on the [body site] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.). There are [no] signs of malignancy(only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.).
Management Plan:
• The lesion is clinically consistent with [diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.).
• [If benign] I have reassured the patient and advised [monitoring, emollients, no further action] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.).
• [If suspicious] I have arranged for [biopsy/excision/photographic monitoring], and we will update you accordingly (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.).
Follow-Up:
[Discharge, routine monitoring, or review in X months] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
If there are any new concerns, please feel free to refer the patient back.
Best regards,
[name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[role] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[contact details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Sample Clinical Note

Example of completed documentation using this template

Dear GP Dr. Smith,
Diagnosis: Basal cell carcinoma.
Treatment History: The patient has previously received cryotherapy for actinic keratosis.
Past Medical History: The patient has a history of hypertension and has a pacemaker.
Drug History: The patient is currently on lisinopril and aspirin.
Allergy History: The patient has a penicillin allergy.
Social History: The patient experiences significant sun exposure due to an outdoor occupation and has a Fitzpatrick skin type II.
Clinical Findings:
John Doe, a 58-year-old male, was evaluated in the dermatology clinic today for a lesion present for six months, with recent rapid growth and occasional bleeding on the left cheek.
On examination, the lesion appears as a pearly, nodular growth with telangiectasia, measuring approximately 1.5 cm in diameter on the left cheek. There are indications of malignancy.
Management Plan:
• The lesion is clinically indicative of basal cell carcinoma.
• I have scheduled an excision, and we will keep you informed.
Follow-Up:
The patient will be reassessed in 3 months following the excision.
If there are any new concerns, please feel free to refer the patient back.
Best regards,  
Dr. Emily Johnson  
Consultant Dermatologist  
emily.johnson@dermaclinic.com
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline dermatological assessments, ensuring thorough documentation of patient history, clinical findings, and management plans. By incorporating high-search healthcare keywords, this template enhances the accuracy and efficiency of clinical documentation, making it an invaluable tool for dermatologists. It facilitates detailed recording of diagnosis, treatment history, past medical conditions, drug and allergy history, and social factors, all crucial for informed decision-making. Clinicians can easily document lesion characteristics and management strategies, promoting consistent patient care and follow-up. Explore this template to optimize your clinical workflow and improve patient outcomes.
Frequently Asked Questions

Common questions about this template and its usage

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