Dermatology Clinic Note (New Patient)

Date of Service: [Date of service]
Location: [Clinic location]
Clinician: [Clinician name and credentials]
Referral Source: [Referring clinician and reason] (Include only if referred; omit if self-referred)

Chief Complaint

[Patient-stated concern(s) in their own words] (List multiple concerns in patient-priority order. Note source if derived from referral paperwork rather than patient.)

History Source

[History source and reliability limitations] (Include only if patient is not the sole reliable historian, e.g., parent/guardian historian, interpreter used, reliance on outside records, memory impairment. Omit this section entirely if not applicable.)

History of Present Illness

(Organize by chief concern using a short paragraph per concern. Document only details explicitly obtained; avoid documenting negatives unless specifically asked and assessed.)

[Concern 1]

[Onset, duration, and course; symptoms with severity and functional impact; anatomic location with laterality and subsite; exposures and precipitants; prior treatments tried and responses; prior diagnostic workup and results; pertinent red flags]

(For specific complaint types, add targeted details: pigmented lesions—evolution/change, different from others; hair/scalp—shedding vs breakage, pattern, triggers, hair practices; nail—single vs multiple, trauma, pigment evolution; acne/rosacea—distribution, triggers, scarring, prior systemic therapy, pregnancy plans; inflammatory dermatoses—BSA extent, prior systemics/biologics.)

(Repeat subsection for each additional concern.)

Dermatologic History

(Omit subsections that do not apply to this patient.)

• Personal skin cancer history: [Melanoma (site, year, stage/treatment, recurrence); keratinocyte carcinomas (BCC/SCC sites, treatments); dysplastic nevi; other cutaneous malignancies] (Note if details are unknown rather than omitting.)
• Family history: [Melanoma or other skin cancers in first-degree relatives with age at diagnosis if known]
• UV exposure: [Occupational/recreational sun exposure; blistering sunburns; indoor tanning history; current sun protection habits]
• High-risk states: [Organ transplant; hematologic malignancy; HIV; chronic immunosuppressive medications]
• Prior dermatology care: [Previous dermatologists and key diagnoses; prior systemic agents with monitoring needs; patch testing results; history of keloids/hypertrophic scarring]

Medical History

[Relevant medical conditions including immunosuppression, diabetes, liver/renal disease, pregnancy status or plans, autoimmune disease, atopy/asthma; relevant surgical history]

Current medications: [Medication list] (Highlight immunosuppressants, anticoagulants, photosensitizers. Note if medication list was reviewed with patient.)

Allergies: [Allergies with reaction types, especially antibiotics, anesthetics, adhesives, latex, topical agents] (Use "No known drug allergies" only if confirmed; use "unknown" if not obtained.)

Social History

[Dermatology-relevant factors: occupation/hobbies with exposure risks; housing/pets/close contacts if relevant to infectious or infestation concerns; tobacco use; sexual history only when clinically indicated for genital dermatoses]

Review of Systems

(Document a targeted ROS relevant to the dermatologic differential. Omit this section entirely if ROS was not performed. Do not state "all other systems negative" unless a comprehensive ROS was actually performed.)

• [Itch/pruritus]
• [Pain/tenderness/burning]
• [Bleeding/non-healing lesions]
• [New/changing moles]
• [Constitutional or other system symptoms relevant to differential: fever, weight loss, night sweats, mucosal/ocular symptoms, joint pain]

Physical Examination

General: [General appearance and vitals] (Include only if measured and relevant.)

Skin Examination: [Scope statement, e.g., "Focused exam of face and scalp" or "Total body skin exam performed including scalp, nails; genital exam declined"] (Document what was offered, declined, and examined.)

(Organize findings by body region or by problem as appropriate.)

• [Region/anatomic area]: [Location with laterality and subsite; morphology; color and secondary changes; size in mm/cm; borders; configuration; distribution pattern; palpation findings]

Dermoscopy: [Dermoscopy features informing management] (Include only if performed.)

Photography: [Sites photographed; images uploaded to chart; consent obtained per policy] (Include only if photos taken.)

Data Reviewed

(Omit this section if no external data were reviewed.)

• [External records, prior notes, pathology reports, labs, or imaging reviewed with dates and sources]
• [Discussion with external clinicians if applicable]

Assessment

(Number problems in order of clinical priority: urgent/malignancy concerns first, inflammatory conditions next, benign incidental findings last.)

1. [Problem 1]: [Working diagnosis or uncertainty framing] — [Key supporting findings from history/exam/dermoscopy]. [Differential diagnosis if uncertainty remains]. [Severity metrics if relevant, e.g., BSA%].
2. [Problem 2]: [Working diagnosis] — [Key supporting findings].

Plan

(Link each plan item to its corresponding numbered assessment problem. Include only applicable elements for each problem.)

1. [Problem 1]:

   • Diagnostics: [Biopsy type and site; cultures; KOH; labs ordered with clinical question]
   • Therapy: [Topical: medication, vehicle, potency class, site, frequency, duration, stopping rules] [Systemic: dose, titration, monitoring plan, contraindications]
   • Procedures: [Reference Procedure Note below if performed]
   • Counseling: [Risks/benefits/alternatives discussed; expected course; adherence guidance]
   • Follow-up: [Return timeframe; results communication method; return precautions]

2. [Problem 2]:

   • [Plan elements as above]

Procedure Note

(Include this section only if a procedure was performed. Create a separate entry for each distinct procedure.)

[Procedure name]

• Procedure: [Name and indication]
• Site: [Anatomic location with laterality; lesion size if applicable]
• Consent: [Risks, benefits, and alternatives discussed; patient questions answered; patient agreed to proceed]
• Verification: [Correct-site verification performed per institutional protocol]
• Technique: [Prep; anesthesia agent, concentration, volume; method and instrument; hemostasis; closure if applicable; dressing]
• Specimen: [Labeled with two patient identifiers; submitted to dermatopathology with clinical impression]
• Complications: [None / description]
• Aftercare: [Wound care instructions provided; suture removal timing if applicable]
• Follow-up: [Plan for communicating pathology results]

Follow-up

[Return intervals by problem; results communication plan; escalation/return precautions]

(For critical safety fields—allergies, pregnancy status when prescribing teratogens, anticoagulant use when performing procedures—explicitly document "denied," "unknown," or "not obtained" rather than leaving blank. Omit sections that were not performed rather than implying normal findings.)