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Templates, Clinical notes, Dermatology

Dermatology follow-up note template

A dermatology follow-up note template that sets out what belongs in each section, ready to adapt to your own clinic. Below it is the same note filled in by the wai scribe from an invented consultation, line by line, for the clinician to read and sign.

Updated . Written by our clinical team, generic by design, with no dosing advice.

01Follow-up note

TemplateDermatology

Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]

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.

Draft

[Clinician name]

[Role], [registration number]

Signed [date], [time]

How the wai scribe fills it

The same note, written from an invented consultation.

Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.

01Follow-up note

SignedAI-assisted, edited by the clinician

Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person

Dermatology follow-up note

1Since the last visit

  • Biopsy site healed. No concerns.00:40

2Examination

  • Left upper back, 7 mm pigmented lesion, two colours, irregular border. Photographed with consent.03:40

3Review

  • Atypical pigmented lesion. Biopsy recommended to exclude melanoma.05:10

4Plan

  • Punch biopsy today. Histology result expected in two weeks, clinician to review.05:50

5Next review

  • Advised to report any other changing lesion.06:30

Signed and filed

[Clinician name]

[Role], [registration number]

Signed [date], [time]

Questions

What goes in a dermatology follow-up note?

Since the last visit, Examination, Review, Plan and Next review. Each section on this page lists what belongs in it, written for dermatology.

Is the worked example a real patient?

No. The consultation is invented for this page, and no real patient or record is used.

Does the scribe sign the note?

No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.

Can we use our own note structure?

Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.

Come back to the note, written and ready to sign.

See the wai scribe write a dermatology follow-up note on your own structure, in a 15 minute video call.