Dermatologist New Patient

Reason for Appointment: [List the patient’s reported issues and reasons for visit as numbered items] (Write each reason or presenting issue as a full sentence. Use a numbered list if multiple reasons are mentioned. Include relevant details such as symptom location, severity, duration, previous evaluations, and any treatments already started or advised. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) History of Present Illness: [Describe the narrative history leading up to the current presentation] (Write as a paragraph in full sentences. Include duration, progression of symptoms, associated symptoms, attempted treatments or medications, relevant encounters with other clinicians or healthcare settings, previous similar episodes, and relevant environmental or travel context. Maintain logical flow and clinical tone throughout. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Current Medications: [List all active medications including name, dose, route, frequency and any notes to pharmacist] (Use bullet-point format. Include generic name and strength, route, frequency, and any notes on adherence or pharmacy status. Include only medications explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) "Medication list reviewed and reconciled with the patient." Active Problem List: [List the active problems] (List each problem individually using a clear and consistent format. Include only the problems explicitly mentioned in the transcript or contextual notes. Omit this section entirely if no problems are referenced.) Past Medical History: [Document relevant past medical history] (Write as a short paragraph. Include only conditions explicitly mentioned in the transcript or contextual notes, particularly those relevant to the presenting issue. Omit completely if not stated.) Family History: [Summarise any family history related to the presenting concern or relevant chronic conditions] (Write as a short sentence or two. Reference only the family history content explicitly mentioned in the transcript or contextual notes; otherwise omit completely.) Social History: [Describe any relevant lifestyle or environmental exposures] (Include details only if mentioned in the transcript or contextual notes. Summarise concisely in a single sentence; otherwise omit completely.) Allergies: [Document allergy status] (Write patient's allergies based on transcript or contextual notes. If any allergies are mentioned, list each one individually along with the reaction type if available. Omit completely if not stated.) Vital Signs: [Document available vital signs] (List any recorded vital signs such as temperature, blood pressure, heart rate, respiratory rate, oxygen saturation, height, and weight. Use standard clinical abbreviations and numeric values. Present all available vital signs on one line or in paragraph format as found in the transcript or contextual notes. Only include if explicitly mentioned; otherwise omit completely.) Examination: Skin Exam: [Describe general appearance and relevant skin findings from physical exam] (Write as a paragraph. Start with a general description of appearance and skin type if included, then detail each area examined using anatomical terms. List any abnormal findings last. Only include details explicitly present in the transcript or contextual notes; otherwise omit completely.) Assessments: [Summarise diagnoses or provisional assessments] (List each diagnosis or assessment using a numbered format. Use diagnostic codes and priority labels if provided in the transcript or contextual notes. Only include if explicitly mentioned; otherwise omit completely.) Treatment: 1. [State the diagnosis being treated] (Provide the diagnosis label exactly as it appears in the transcript or contextual notes. Each numbered item should start with a different diagnosis if multiple are being treated. Only include if explicitly mentioned; otherwise omit completely.) [Document the medications prescribed for the above diagnosis, including name, dose, route, frequency, duration, refills, and any notes to pharmacist] (Use full sentences. Include each component of the prescription — drug name, dose, route, frequency, duration, number of refills, and any dispensing instructions. Format the medication details consistently, separated by commas. Only include if explicitly mentioned; otherwise omit completely.) [Describe any non-pharmacological treatments or clinical advice related to this diagnosis] (Write as part of a continuous paragraph following the medications, if applicable. Include procedures, lifestyle advice, referrals, or monitoring instructions directly associated with the diagnosis. Only include if explicitly mentioned; otherwise omit completely.) (Repeat the format above for each additional diagnosis if more than one is addressed in the treatment plan.) Follow-Up: [Describe follow-up recommendations and timeframes] (Write in one sentence. Include timeframe, follow-up provider, and any specific conditions for follow-up. Phrase and format should align with the structure found in the transcript or contextual notes. Only include if explicitly mentioned; otherwise omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)