<u>Dermatology Consultation Note</u>
Referring Doctor: Dr. Emily Carter
Reason for Referral: Evaluation of a suspicious mole on the patient's back.
Chief Complaint: Patient presents with a new and changing mole on their back that they are concerned about.
Impression:
* Suspicious nevus, likely dysplastic.
* Rule out melanoma.
Plan:
* Excisional biopsy of the suspicious mole.
* Patient education on sun protection and skin self-exams.
* Schedule follow-up appointment for biopsy results.
Counselling: Discussed the importance of sun protection, including the use of sunscreen, protective clothing, and avoiding peak sun hours. Explained the procedure for the biopsy and potential risks and benefits. Reviewed the signs and symptoms of melanoma and the importance of regular skin self-exams.
Follow up: Patient to return in 2 weeks for biopsy results and further management.
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History: The patient noticed a new mole on their back approximately 3 months ago. The mole has been changing in size, shape, and colour. There is no family history of skin cancer.
Previous Dermatologic Issues: None.
Previous Dermatologic Medications: None.
Physical Exam: Atypical mole noted on the patient's back, measuring 8mm in diameter, with irregular borders and multiple colours. No other suspicious lesions noted.
Past Medical History: Unremarkable.
Medications: None.
Allergies: No known drug allergies.
Family History: Non-contributory.
**Social History:** The patient works outdoors and reports frequent sun exposure.
Insurance Type: NHS
Procedure Note: Excisional biopsy of the suspicious mole performed. Local anaesthesia used. The site was closed with sutures.
Dr. Thomas Kelly, Consultant Dermatologist
On behalf of Dr. Sarah Jones
<u>Dermatology Consultation Note</u>
Referring Doctor: [name of referring doctor] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Reason for Referral: [reason for referral] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Chief Complaint: [chief complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Impression: [impression] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan: [plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Counselling: [counselling] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Follow up: [follow up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; 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 include 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. Include small summaries of side effects of medications that are prescribed and include the specific potency and dose. Form complete point-form sentences for the impression, plan, history and physical exam. Present the impression and plan in a list format in the order they were mentioned.)
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History: [history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Previous Dermatologic Issues: [previous dermatologic issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Previous Dermatologic Medications: [previous dermatologic medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Physical Exam: [physical exam] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical History: [past medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medications: [medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Allergies: [allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family History: [family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Social History:** [social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Insurance Type: [insurance type] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Procedure Note: [procedure note] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Clinician Name, Credentials and Specialty] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
On behalf of Dr. [Staff Physician Name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; 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 include 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.)
