Follow-up skin surveillance

Chief Complaint

Medical Note Template -- Follow-up Skin Surveillance

Skin history

[Summarize the patient’s skin-related medical history, including any chronic conditions or prior diagnoses.]

Interval history

[Document the time since the last visit and any updates or changes in the patient’s condition.] * [Note any specific concerns or requests from the patient.] * [Include any relevant denials, such as symptoms not present.] * [Mention any protective measures the patient is taking, e.g., sunscreen use, protective clothing.]

Past Medical History

[List the patient’s past medical conditions.] * [Condition 1] * [Condition 2] ...

Interval change in medical history

[Document any new medical conditions or treatments since the last visit. Include details such as duration and expected conclusion of treatment.]

Current Medications

[List all current medications, including name, purpose, and duration if applicable.] * [Medication 1: purpose/duration] * [Medication 2: purpose/duration] ... [Note any updates regarding medication allergies.]

Follow up

[Indicate the purpose of the follow-up visit, e.g., skin surveillance or other specific concerns.]

Follow up skin surveillance

[Provide a brief description of the reason for skin surveillance or any relevant context.]

Physical Examination

[Summarize the findings of the physical examination, including general appearance and specific areas examined.] * [General observations, e.g., systemically well or unwell.] * Scalp: [Findings] * Trunk: [Findings] * Face: [Findings] * Bilateral ear helix: [Findings] [Include pertinent negatives, e.g., absence of concerning lesions for malignancy.]

Assessment and Plan

[Provide a detailed assessment of the patient’s conditions and the corresponding plan for each. Use numbered points for clarity.] 1. [Condition 1: Assessment] Plan: * [Action 1] * [Action 2] ... 2. [Condition 2: Assessment] Plan: * [Action 1] * [Action 2] ... 3. General Skin Health: Plan: * [Educate the patient on monitoring for new or concerning skin changes. Include specific guidance, e.g., ABCDE melanoma criteria.] * [Outline follow-up recommendations or discharge instructions.] * [Indicate willingness to see the patient again if new concerns arise.]

Assessment and Plan

[Provide a detailed assessment of the patient’s conditions and the corresponding plan for each. Use numbered points for clarity.] 1. [Condition 1: Assessment] Plan: * [Action 1] * [Action 2] ... 2. [Condition 2: Assessment] Plan: * [Action 1] * [Action 2] ... 3. General Skin Health: Plan: * [Educate the patient on monitoring for new or concerning skin changes. Include specific guidance, e.g., ABCDE melanoma criteria.] * [Outline follow-up recommendations or discharge instructions.] * [Indicate willingness to see the patient again if new concerns arise.]