Intake- Skin Check

OVERALL_INSTRUCTIONS

Template

Chief Complaint: [Chief complaint — specify reason for consultation, e.g., Full skin examination, evaluation of specific lesions, etc.] Pertinent skin cancer history: [Pertinent skin cancer history — if not provided, default to “No prior basal cell carcinoma, squamous cell carcinoma or melanoma.”] History of Present Illness: - [Age]-year-old [gender] presents for evaluation and treatment of [specific skin concern]. - Reports [description of lesions or symptoms]. - Denies [pertinent negatives — e.g., any lesions that are painful, rapidly growing, or bleed spontaneously]. Pertinent negatives: [Additional pertinent negatives — if not provided, default to “No history of radiation therapy, immunosuppression. Non-smoker.”] Past Medical History: -[Relevant past medical history — list conditions, e.g., history of colitis, shingles, etc.] Social History: - [Living situation — e.g., Lives in a nursing home, with family, etc.] -[Family details — e.g., number of children, proximity, etc.] -[Insurance or drug coverage — e.g., NS Pharmacare drug coverage.] - [Smoking status — if not provided, default to “Non-smoker.”] Current Medications: [Current medications — list medications and dosages, e.g., B12 injections, iron pills every other day.] Allergies: -[Allergies — if not provided, default to “No known drug allergies.”] Physical Examination: - [General appearance — if not provided, default to “Appears systemically well.”] -Full skin exam done. -Face: [Findings on face — e.g., Two hypertrophic actinic keratoses noted on the left nasal sidewall and left medial cheek.] -Trunk: [Findings on trunk — e.g., Resolving seborrheic keratoses observed on the left shoulder.] - Lower legs: [Findings on lower legs — e.g., A benign seborrheic keratosis is present on the right leg.] -[Additional findings — if not provided, default to “No concerning regions of malignancy identified.”] Assessment and Plan: 1. [Condition 1 — e.g., Actinic Keratoses: Two hypertrophic lesions] Plan: -[Treatment performed — e.g., Cryotherapy performed during the visit.] -[Patient education — e.g., Educated the patient on post-treatment care and expected healing process.] -[Response to treatment — if not provided, default to “Tolerated well.”] 2. [Condition 2 — e.g., Seborrheic Keratoses] Plan: - [Treatment plan — if not provided, default to “No treatment necessary. Reviewed benign nature of lesion.”] - [Monitoring plan — e.g., Continue to monitor for any changes in the lesions.] 3. General skin health Plan: -[Preventative measures — e.g., Encouraged photoprotection.] -[Patient education — e.g., Reviewed ABCDE's of melanoma and signs of non-melanoma skin cancer.] - [Self-monitoring — if not provided, default to “Encourages self-examinations q3-4 months.”] Follow up: - [Follow-up plan — if not provided, default to “No formal follow-up organized based on relatively benign exam. Discharge to primary care provider. Happy to see if new or concerning lesions are noted.”]