Skin Cancer Surveillance Follow-Up Note

Date: [Date]

Visit Type: [in-person / telederm]

Clinician: [Clinician name and credentials]

Reason for Visit: Skin cancer surveillance follow-up

Chief Concern / Interval History

[One-line chief concern in patient-centered language] (Include any secondary concerns such as new or changing lesions noticed by the patient.)

[Interval history since last visit] (Summarize only what has changed: new or changing lesions with location, duration, and symptoms; any treatments or biopsies performed elsewhere; interval systemic symptoms relevant to melanoma surveillance if applicable—new lumps, persistent cough, headaches, unexplained weight loss, bone pain; self-surveillance behaviors. If no interval changes, state: "Patient reports no new or changing lesions and no concerning systemic symptoms since last visit.")

Skin Cancer History (Reviewed/Updated)

• Melanoma: [Primary site]; [Diagnosis date]; [Breslow depth]; [Ulceration: present/absent/unknown]; [SLNB result]; [AJCC stage]; [Treatment] (If any element unknown, document "Unknown" and whether records have been requested.)
• NMSC: [Site(s) and date(s)]; [Histology]; [High-risk features if any]; [Treatment type]
• Risk modifiers: [Dysplastic nevi / high nevus count / immunosuppression / genetic syndromes / other relevant risks] (Include only if applicable.)

Prior history reviewed and updated as needed.

Examination

Exam Scope: [TBSE / Focused exam] (Note any areas not examined and why. State use of dermoscopy and/or clinical photography. For telederm, describe image sources and limitations.)

• Skin Findings: [Grouped background findings without concerning features]
• Actionable lesion(s): [Location; size; morphology; clinical impression; plan] (Add additional bullets for each actionable lesion. Omit if none.)
• Prior cancer site(s): [Site: scar appearance; presence/absence of nodularity, pigment recurrence, ulceration, satellite lesions] (Add additional bullets for each prior melanoma or high-risk NMSC site.)

Lymph Node Exam: [Basins examined and findings] (Include for melanoma and high-risk cSCC. Omit for low-risk BCC-only surveillance.)

Assessment & Plan

(Organize by problem, highest risk first.)

Melanoma surveillance ([Stage/Risk Category]): [Status summary: scar exam, lymph node exam, symptom screen, TBSE findings] [Surveillance status: No evidence of recurrence / Concerning finding under evaluation] — Next follow-up: [interval and rationale tied to stage]. [Imaging/labs if indicated; referrals if applicable]. (If staging unknown, note conservative interim plan pending records.)

NMSC surveillance ([Type and risk level]): [Status summary: high-risk features if any; scar exam findings; surveillance status] — Next follow-up: [interval and rationale]. [Field treatment plans if applicable.]

New or changing lesion(s): [Lesion: location, clinical impression] — [Action: biopsy / treatment / observation with rationale and return triggers] (Add additional entries for each lesion addressed. Omit section if none.)

Counseling: [Monthly self-skin exam with ABCDE warning signs; sun protection; urgent return precautions (rapidly changing pigmented lesion, new firm lymph node, nonhealing lesion, systemic red flags)] — Patient verbalizes understanding.

Follow-up: [Next dermatology visit: interval and type] [Imaging/labs ordered or not indicated] [Referrals placed if any] [Return precautions and contact instructions for earlier evaluation]

Procedures

(Omit entire section if no procedures were performed.)

• Indication: [Reason for procedure]
• Site: [Anatomic location and laterality]
• Procedure: [Shave biopsy / Punch biopsy / Excision / ED&C / Cryotherapy / Other] (Include anesthesia, technique, hemostasis.)
• Specimen handling: [Labeled and sent to pathology]
• Aftercare: [Wound care instructions provided; signs of infection reviewed]
• Post-procedure plan: [Pathology follow-up plan; suture removal timing if applicable]