XL skin check template

"Verbally consented to the use of AI for note-taking." **Reason for Visit** [reason for visit] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe current issues, reasons for visit, discussion topics, and history of presenting complaints.) **Other Medical Issues Discussed** [other medical issues] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.) **History** (Repeat the following format for each issue discussed. Number each issue sequentially. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.) [issue description] (Describe the issue in detail, including symptom quality and severity, symptom duration, recent illnesses or events, associated symptoms, current treatments and their effects, and treatment planned for this issue if applicable.) **Medical History** [past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. List in dot points. Specifically list if there is a pacemaker in situ. Include negative findings.) **Skin Cancer History** [skin cancer history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe specific skin cancer history in dot points and chronologically if the dates are known. Describe previous skin cancer surgeries and list these chronologically in dot points if the dates are known.) **Skin Type Phototype** [Fitzpatrick skin type] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Classify using the Fitzpatrick scale based on the patient's description of their skin's response to sun exposure: Type 1 — always burns, turns red, never tans; Type 2 — burns easily, tans poorly, fair skin; Type 3 — tans after initial burn or turning red; Type 4 — burns sometimes but mostly tans; Type 5 — rarely burns or turns red, tans darkly easily; Type 6 — never burns, always tans darkly, dark brown or black skin.) **Past UV Exposure and Social History** [UV exposure and social history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe social history including sun exposure, tanning bed use, occupation, lifestyle factors, episodes of sunburn with peeling skin, number of solarium uses, exposure to arsenic, exposure to dyes, any presence or history of immunocompromise, history of autoimmune disease, history of using immunosuppressive drugs or chemotherapy, history of bone marrow transplant, history of adherence to sun-smart measures and sunscreen use, and outdoor hobbies.) **Medications** [medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. List medications and herbal supplements. Specifically include any anticoagulant medications.) **Allergies** [allergies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely.) **Family History** [family history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe relevant family history of skin cancer or other relevant conditions.) **Physical Examination, Assessment and Plan for Each Skin Lesion** "All lesions were examined with a dermatoscope." "Patient was asked if there are any specific lesions they were worried about under their undergarments and given the opportunity for me to examine them if there was a concern." "Photographs of the lesions were taken with patient consent." (Repeat the following format for each lesion examined. Number each lesion sequentially. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. List benign lesions if mentioned, including junctional naevi, compound naevi, dermal naevi, angiomas, seborrhoeic keratosis, and elastoses. If a lesion is re-examined later in the consultation, include additional comments under the heading where it was first mentioned. If tattoos are present, state: "Advised patient that the colouring in tattoos makes it hard to diagnose and spot any possible sinister lesions as it interferes with the algorithm of diagnosis which is reliant on colour.") Lesion [number]: [lesion examination findings] (Describe where the lesion is on the body and what size. Include whether the lesion is symmetrical, whether it is chaotic according to the Chaos and Clues algorithm by Cliff Rosendahl, whether it is pigmented, whether it is raised. Note presence or absence of: white clues, polymorphous vessels or arborising vessels, ulceration, peripheral black dots or blots, eccentric structureless area, blue or grey structures, thick lines, radial lines or pseudopods, white lines, parallel ridge pattern, erythematous pseudonetwork.) - [assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit. Provide an assessment of the findings, including any differential diagnoses.) - [plan for this lesion] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit. Outline the plan for further investigation, including biopsies or referrals. Specifically mention the interval of follow-up if discussed.) **Plan** [overall plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Outline the overall plan for further investigation, including biopsies, imaging, or referrals. Use dot points. Include any potential complications of the procedures.) [treatment options] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Describe treatment options, including surgical removal, topical treatments, or other therapies.) [follow-up plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Mention follow-up appointments and monitoring plan.) **Patient Education** [patient education] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Provide information on skin cancer prevention, including sun protection, self-examination techniques, and warning signs to watch for. Note the interval of follow-up and mention that there is no specific recommendation from the health board on how often to have a skin check.) **Clinician's Notes** [clinician's notes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Include any additional notes or observations made by the clinician.) (Use Australian English spelling throughout. Use Australian spelling of medications. Write the entire note in British English. Do not include comments such as "not mentioned". Do not put any words in brackets in the output. Do not include any comment about MyMedicare registration. Do not include any comment about My Health Record. Do not start any sentence with "The patient". Do not include email addresses or phone numbers. Do not start any sentence with "Clinician" or "GP". Do not write anything about patient details at the start of the text. Include negative findings in medical history and examination. Do not include profanity if used during the consultation. Do not begin sentences with a dash. Do not leave a bullet point without a sentence after it. Do not start the note with "C/O".)