Dermatology follow-up note
1Since the last visit
- What has changed since the last visit, in the patient's words.
- Results received since the last visit, and whether they were discussed.
2Examination
- Site, size, shape, colour and border of each lesion, with a body map reference.
- Dermoscopy findings where used, and photographs taken with consent.
3Review
- The working diagnosis and the differentials, including whether anything is suspicious.
- Whether a biopsy or an urgent referral is needed.
4Plan
- Investigations requested, and who will follow up the result.
- Treatment agreed, as prescribed in the prescribing record.
- Referrals made, and what was explained to the patient.
5Next review
- What should prompt the patient to get back in touch, and how.
- When the next review is due.
