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Dermatologist-Vorlage

Full Skin Examination

Eine professionelle Dermatologist-Vorlage für medizinisches Fachpersonal.
Vorlage verwendenVorlagen durchsuchen

Fachgebiet

Dermatologist

Genutzt

32 Zeiten

Art

Note

Zuletzt bearbeitet

8.10.2025

Erstellt von

parzhin piran

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Über diese Vorlage

Need a comprehensive skin check documented? This 'Full Skin Examination' template is perfect for dermatologists and other skin specialists. It guides you through a thorough assessment, from patient history and risk factors to detailed examination findings, including descriptions of concerning lesions. The template ensures all relevant details are captured, aiding in accurate diagnosis and treatment planning. With Heidi, this template can be quickly populated from your consultation transcript, saving you time and improving the accuracy of your clinical documentation. This template is designed to help you create detailed and accurate medical documentation.

Vorlagenvorschau

Eleanor Vance consented for medical AI. Presenting for skin check. History of Presenting Complaint: * History of previous skin cancers, specifying melanoma versus non-melanoma skin cancers (NMSCs): Patient reports a history of basal cell carcinoma (BCC) diagnosed in 2018. * Dates of most recent diagnoses of skin cancers, including Breslow thickness or Clark level if provided: BCC diagnosed in 2018, treated with excision. No recurrence. * Relevant risk factors including childhood sun exposure, occupational exposure, family history of skin cancers, geographical location, relevant hobbies, and current or past sun protection practices: Patient reports significant childhood sun exposure, fair skin, and a family history of skin cancer (mother). Patient uses SPF 30 sunscreen daily. * Patient concern regarding specific lesions: Patient is concerned about a new mole on her back that has changed in size and colour. Examination: * FSE down to underwear under appropriate lighting. * Fitzpatrick skin type: Type II. * Objective findings from full skin check, including any noted lesions or sites if explicitly mentioned: Multiple benign nevi noted. One suspicious lesion on the upper back. * Lesions of concern: 1. Description and site of first lesion of concern: Asymmetrical, irregular borders, and varying shades of brown, measuring 6mm on the upper back. 2. Description and site of second lesion of concern: None. 3. Additional lesions of concern with description and site: None. Plan: * Management plan including biopsy, excision, or monitoring recommendations: Biopsy of the suspicious lesion on the upper back. * Preventative measures or counselling discussed: Discussed sun protection measures, including regular sunscreen use, avoiding peak sun hours, and regular skin self-exams. * Follow-up instructions: Follow-up in two weeks for biopsy results. Schedule a full skin check in six months.

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