Intake note - Skin check

Chief Complaint

[State the patient's primary reason for the visit, including any specific concerns or symptoms related to the skin. For example: Full skin examination or evaluation of specific lesions.]

Pertinent skin cancer history

[Document any relevant history of skin cancer, including prior diagnoses such as basal cell carcinoma, squamous cell carcinoma, or melanoma. Include pertinent negatives if applicable.]

History of Present Illness

[Provide a detailed narrative of the patient's current skin concerns. Include the following:] * [Patient's age and gender, reason for visit, and description of skin lesions or symptoms.] * [Details about the lesions, including location, duration, and any prior treatments.] * [Patient-reported symptoms such as pain, growth, or bleeding.] * [Pertinent negatives, such as absence of radiation therapy, immunosuppression, or smoking history.]

Past Medical History

[List the patient's relevant medical history, including chronic conditions and significant past illnesses.] For example: * [Condition 1] * [Condition 2]

Social History

[Provide details about the patient's living situation, family support, lifestyle habits, and other relevant social factors.] For example: * [Living situation] * [Family details] * [Drug coverage or insurance] * [Smoking status]

Current Medications

[List all current medications the patient is taking, including dosage and frequency.] For example: * [Medication 1] * [Medication 2]

Allergies

[Document any known drug allergies or state 'No known drug allergies' if applicable.]

Physical Examination

[Describe the findings from the physical examination, including a full skin exam if performed. Include the following:] * [General appearance of the patient.] * [Findings on the face, trunk, and extremities, including descriptions of lesions or abnormalities.] * [Note any concerning or benign findings.]

Assessment and Plan

[Provide an assessment of the patient's condition and a detailed plan for management. Include the following:] 1. [Condition 1: Assessment and plan, including any treatments performed during the visit.] Plan: * [Details of treatment, patient education, and follow-up instructions.] 2. [Condition 2: Assessment and plan, including whether treatment is necessary.] Plan: * [Details of monitoring or education provided.] 3. [General skin health: Recommendations for skin care and prevention.] Plan: * [Encourage photoprotection, review signs of skin cancer, and recommend self-examinations.] [Include follow-up instructions, such as whether a formal follow-up is needed or if the patient is discharged to primary care. Offer to see the patient again if new or concerning lesions arise.]

Assessment and Plan

[Provide an assessment of the patient's condition and a detailed plan for management. Include the following:] 1. [Condition 1: Assessment and plan, including any treatments performed during the visit.] Plan: * [Details of treatment, patient education, and follow-up instructions.] 2. [Condition 2: Assessment and plan, including whether treatment is necessary.] Plan: * [Details of monitoring or education provided.] 3. [General skin health: Recommendations for skin care and prevention.] Plan: * [Encourage photoprotection, review signs of skin cancer, and recommend self-examinations.] [Include follow-up instructions, such as whether a formal follow-up is needed or if the patient is discharged to primary care. Offer to see the patient again if new or concerning lesions arise.]