Total-Body Skin Exam Note

Date: [Date]

Patient: [Patient name]

Provider: [Provider name and credentials]

Visit Type: [Screening TBSE / Surveillance TBSE / Lesion-directed with TBSE]

Reason for Visit

[Reason for TBSE including whether screening or surveillance, relevant history context, and patient concerns] (Write 1–2 sentences.)

Risk Factors

• Personal history (melanoma, NMSC, atypical nevi): [present / absent / not assessed] (If present, specify conditions and years.)
• Family history of melanoma (first-degree): [present / absent / not assessed] (If present, specify relation.)
• UV exposure history: blistering sunburns [yes / no / not assessed]; tanning bed use [yes / no / not assessed]
• Immunosuppression: [present / absent / not assessed] (If present, specify cause.)
• High nevus burden: [yes / no / not assessed]

Objective

Exam Extent: TBSE performed including scalp, face/ears, neck, trunk, buttocks/groin, upper and lower extremities, hands/feet, and nails. [No limitations / Area(s) not examined: [area] — [reason]]

Chaperone: [Chaperone offered and accepted with name/role / Chaperone offered and declined / Not applicable] (Omit line if not applicable.)

Tools: [Dermoscopy / Clinical photography / Total body photography / None] (Include all that apply.)

General Findings: [Summary of background photodamage, nevus pattern, actinic keratoses, or other pertinent findings]

Notable Lesions

(Include only if lesion requires monitoring, treatment, or biopsy. Omit entire subsection if none.)

• Lesion [#]: [Side and anatomic site]; Size: [mm]; Morphology: [type, color, border, symptoms]; Dermoscopy: [key features / not performed]; Impression: [clinical impression]

Lymph Nodes: [Basins examined] — [no adenopathy / adenopathy noted at location] (Include only for melanoma surveillance or when clinically indicated; otherwise omit.)

Assessment

[Clinical summary synthesizing risk level, key findings, and actions taken] (1–2 sentences.)

• [Problem]: [Diagnosis or working impression]; [new / stable / changed]; [rationale if biopsy or treatment performed]

Plan

(Organize by problem. Include intervention, rationale when non-obvious, and follow-up.)

• [Problem]: [Intervention or management plan]; [follow-up interval and criteria for earlier return]

Counseling: [Sun protection and self-skin exam guidance provided] (Include for elevated-risk patients or premalignant/malignant findings. Omit if not provided.)

Procedures: [Procedure type] at [site matching lesion #]; anesthesia [agent/amount]; specimen [sent to dermatopathology / none]; wound care instructions given. (Omit if no procedures. Reference separate procedure note if documented elsewhere.)

Follow-up: Return in [interval] based on [risk stratification rationale]. Return sooner if [precautions]. Pathology results via [phone / portal] within [timeframe].

(Use "not assessed," "unknown," or "deferred" when information is missing rather than omitting or defaulting to negative.)