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Templates, Clinical notes, Dermatology

Dermatology procedure note template

A dermatology procedure 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.

01Procedure note

TemplateDermatology

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

Dermatology procedure note, punch biopsy

1Indication

  • The lesion, its location and why histology is needed.

2Consent

  • How consent was taken, and the risks, benefits and alternatives discussed.
  • Whether written consent is on the record, with its date.

3Procedure

  • Site, method and closure, with the specimen labelled at the bedside.
  • Patient identity and site confirmed and marked before starting.

4Findings

  • Specimen sent, the laboratory and the pathway for the result.

5Complications

  • Any complication, or a record that there were none.
  • Anything that did not go to plan, and what was done about it.

6Aftercare and follow-up

  • Aftercare advice given, verbally and in writing.
  • Follow-up arranged, and what should prompt the patient to get in touch sooner.

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.

01Procedure note

SignedAI-assisted, edited by the clinician

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

Dermatology procedure note

1Indication

  • Changing pigmented lesion, left upper back. Histology required.00:45

2Consent

Completed by the clinician from the record.

3Procedure

  • Local anaesthetic infiltrated. 4 mm punch biopsy taken. Site and identity confirmed before starting.04:00

4Findings

  • Specimen labelled at the bedside and sent to [laboratory].07:10

5Complications

Completed by the clinician from the record.

6Aftercare and follow-up

  • Dressing for 24 hours. Suture removal in ten days. Wound care leaflet given.08:00

Signed and filed

[Clinician name]

[Role], [registration number]

Signed [date], [time]

Questions

What goes in a dermatology procedure note?

Indication, Consent, Procedure, Findings, Complications and Aftercare and follow-up. 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 procedure note in other specialties

All clinical notes
  1. Private GPPrivate GP procedure note
  2. AestheticsAesthetics procedure note
  3. FertilityFertility procedure note
  4. PhysiotherapyPhysiotherapy procedure note
  5. Mental healthMental health procedure note
  6. DentalDental procedure note
  7. Longevity medicineLongevity medicine procedure 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 procedure note on your own structure, in a 15 minute video call.

Request a demoEmail us