Teledermatology Visit Note

Date/Time: [Date and time of service]

Patient: [Patient name and identifier]

Visit Type: [synchronous video / asynchronous store-and-forward / hybrid]

Patient Location: [City, State at time of service]

Telehealth Consent: [verbal / written]; [Consent date]

Media Review

Images/video reviewed: [patient-submitted photos / clinician-acquired photos / dermoscopy images / live video], [number], [regional / close-up / both] views. Diagnostic quality: [Adequate / Limited / Inadequate]. [Limiting factors if present: blur, poor lighting, no scale, incomplete views, color fidelity concerns, or none.] Assessment pathway: [proceed with remote assessment / request repeat images / schedule in-person evaluation]. (If no images available, state: "No images available; audio-only encounter.")

History

Chief Complaint: [Patient-stated concern in their own words]

[HPI narrative: onset and duration; anatomic location(s); symptoms (itch, pain, bleeding); evolution or changes; prior treatments and response; relevant exposures or triggers; patient-provided context about images including whether photos reflect current appearance and any self-measurements. Incorporate pertinent positives and negatives within this narrative.]

Allergies: [Relevant allergies / NKDA / not confirmed—verify before dispensing] (Include only if prescribing anticipated.)

Relevant Medications: [Immunosuppressants, anticoagulants, current topicals, or other pertinent therapies] (Include only if relevant to the concern.)

Skin Cancer Risk Factors: [Personal history, immunosuppression, severe sun exposure, tanning bed use] (Include only when evaluating a suspicious lesion.)

Remote Exam

Exam Method: [Exam via reviewed photographs / Live video exam / Hybrid]

[Morphology-based description: anatomic site(s); primary lesion type (macule, papule, plaque, nodule, vesicle, etc.); secondary changes (scale, crust, erosion); color; border characteristics; configuration; distribution. Size: measured/patient-reported/estimated with units and source labeled.] (Do not describe palpation-dependent findings unless explicitly patient-reported and labeled as such. Include dermoscopy findings only if dermoscopy images were reviewed.)

Limitations: Assessment based on images and history provided; palpation-dependent features cannot be assessed; color accuracy may be limited by camera/lighting; only imaged areas were evaluated. [Case-specific limitations as relevant.]

Assessment

[Problem]: [Working diagnosis]. Differential: [2–4 alternatives if uncertain]. Certainty: [high / moderate / low] based on [image quality and exam limitations]. Triage: [manage remotely / routine in-person follow-up / urgent in-person evaluation / emergency referral]. Rationale: [One sentence linking observed features and limitations to triage decision.]

(Repeat for each distinct problem evaluated. Begin clinical reasoning with "Based on images and history provided.")

Plan

[Problem]:

• Treatment: [Medication name, strength, vehicle, dose/frequency, duration; adjunctive measures]
• Additional Images: [Repeat or additional images requested with acquisition instructions: lighting, focus, scale reference, regional + close-up] (Include only if needed.)
• Follow-Up: [Timing and modality]
• Safety-Net: [Specific symptoms or changes requiring urgent/emergency evaluation: rapid spread, fever, bleeding, ulceration, signs of severe drug reaction]
• Escalation: [Steps if no improvement or remote pathway unsuccessful]

(Repeat for each problem. Omit inapplicable items. Keep the note problem-centered and concise.)