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Templates, Clinical notes, Dermatology

Dermatology initial consultation note template

A dermatology initial consultation 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.

01Initial consultation note

TemplateDermatology

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

Dermatology initial consultation note

1Presenting complaint

  • The reason for the visit, in the patient's own words where they are useful.
  • How long it has been going on.

2History of the presenting complaint

  • When the lesion or rash appeared, and how it has changed in size, shape or colour.
  • Itch, bleeding or pain, and sun exposure history.

3Past history, medicines and allergies

  • Relevant past medical and surgical history.
  • Current medicines, including anything bought over the counter.
  • Allergies and the reaction each one caused, or a record that none are known.

4Social and family history

  • Occupation, smoking, alcohol and anything else relevant to the complaint.
  • Family history where it changes risk or management.

5Examination

  • Site, size, shape, colour and border of each lesion, with a body map reference.
  • Dermoscopy findings where used, and photographs taken with consent.

6Impression

  • The working diagnosis and the differentials, including whether anything is suspicious.
  • Whether a biopsy or an urgent referral is needed.

7Plan

  • 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.

8Safety-netting

  • 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.

01Initial consultation note

SignedAI-assisted, edited by the clinician

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

Dermatology initial consultation note

1Presenting complaint

  • Mole on the back, darker over the last three months.00:30

2History of the presenting complaint

  • Intermittent itch. Partner reports an increase in size. No bleeding.01:20

3Past history, medicines and allergies

Completed by the clinician from the record.

4Social and family history

Completed by the clinician from the record.

5Examination

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

6Impression

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

7Plan

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

8Safety-netting

  • 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 initial consultation note?

Presenting complaint, History of the presenting complaint, Past history, medicines and allergies, Social and family history, Examination, Impression, Plan and Safety-netting. 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.

The initial consultation note in other specialties

All clinical notes
  1. Private GPPrivate GP initial consultation note
  2. AestheticsAesthetics initial consultation note
  3. FertilityFertility initial consultation note
  4. PhysiotherapyPhysiotherapy initial consultation note
  5. Mental healthMental health initial consultation note
  6. DentalDental initial consultation note
  7. Longevity medicineLongevity medicine initial consultation note

Further reading

  1. ProductThe AI medical scribe for clinics
  2. Read nextWho signs an AI clinical note, and how to review it
  3. Read nextSOAP and specialty note templates for an AI scribe
  4. RegulatorThe CQC compliance hub

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

See the wai scribe write a dermatology initial consultation note on your own structure, in a 15 minute video call.

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