(Always refer to the patient by their name if available. Only refer to them as 'the patient' if there is no information about the patient's name in the patient details.)
Diagnosis:
[1. Dermatological Issue or Condition 1 (issue, request or condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Assessment, likely diagnosis for Issue 1 (condition name only)] (Only include if explicitly mentioned...)
- [Differential diagnosis for Issue 1] (Only include if explicitly mentioned...)
- [Investigations for Issue 1] (Only include if explicitly mentioned...)
- [Treatment for Issue 1] (Only include if explicitly mentioned...)
- [Relevant referrals for Issue 1] (Only include if explicitly mentioned...)
[2. Issue, problem or request 2 (issue, request or condition name only)] (Only include if explicitly mentioned...)
- [Assessment, likely diagnosis for Issue 2 (condition name only)] (Only include if explicitly mentioned...)
- [Differential diagnosis for Issue 2] (Only include if explicitly mentioned...)
- [Investigations for Issue 2] (Only include if explicitly mentioned...)
- [Treatment for Issue 2] (Only include if explicitly mentioned...)
- [Relevant referrals for Issue 2] (Only include if explicitly mentioned...)
[3. Issue, problem or request 3, 4, 5 etc] (Only include if explicitly mentioned...)
- [Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only)] (Only include if explicitly mentioned...)
- [Differential diagnosis for Issue 3, 4, 5 etc] (Only include if explicitly mentioned...)
- [Investigations for Issue 3, 4, 5 etc] (Only include if explicitly mentioned...)
- [Treatment for Issue 3, 4, 5 etc] (Only include if explicitly mentioned...)
- [Relevant referrals for Issue 3, 4, 5 etc] (Only include if explicitly mentioned...)
Treatment:
[Medical treatment, detailing the type of topical or systemic medication, dosage, expected outcomes, potential side effects, etc.] (Only include if explicitly mentioned...)
Note to GP: please continue to prescribe the above as required.
Please arrange the following investigations as the patient is self funding [include only if explicitly mentioned].
Follow-up:
[Follow-up details] (Only include if explicitly mentioned...)
Investigations:
[Investigations, specifying any biopsy, laboratory tests, imaging, etc.] (Only include if explicitly mentioned...)
[Investigations with results, start with date written as day/month/year, including biopsy results, patch testing, laboratory tests, imaging, etc.] (Only include if explicitly mentioned...)
Past Skin History:
[Start with date written as day/month/year, highlighting any previous dermatological diagnoses, treatments, surgeries, outcomes, etc.] (Only include if explicitly mentioned...)
Past Medical History:
(Never use bullet points to write the medical section below. Use full sentences and separate lines for each different medical condition.)
[Past medical and surgical history, start with date written as year, highlighting any previous non-dermatological diagnoses, treatments, surgeries, outcomes, etc.] (Only include if explicitly mentioned...)
Medication:
[Current medications, including any topical treatments, over-the-counter medications, supplements, treatments for skin conditions, etc.] (Only include if explicitly mentioned...)
Allergies:
[Allergies, including medications, topical agents, or substances that may affect skin health, foods etc.] (Only include if explicitly mentioned...)
Family History:
[Family history specific to dermatological issues, such as skin cancer, psoriasis, eczema, asthma, hayfever, acne, hidradenitis suppurativa.] (Only include if explicitly mentioned...)
Social History:
[Social history, focusing on lifestyle factors such as sun exposure, skincare routine, occupation, hobbies, alcohol consumption.] (Only include if explicitly mentioned...)
I reviewed the above [age if specified] year old [gender as lady/gentleman/child/infant, as applicable] (Only include if explicitly mentioned...). My clinical notes from today are as follows:
Subjective:
(Never use bullet points to write the subjective section below. Use full sentences and paragraph format.)
[Reason(s) for consultation, including specific dermatological concerns or symptoms such as rashes, lesions, acne, psoriasis, eczema, changes in mole appearance, hair loss, etc.] (Only include if explicitly mentioned...)
[Detailed history of the presenting complaint(s): onset, duration, severity, aggravating/alleviating factors, associated symptoms (itching, pain, bleeding), previous treatments and responses.] (Only include if explicitly mentioned...)
[Current issues, reasons for visit, history of presenting complaints etc.] (Only include if explicitly mentioned...)
[Mention duration, timing, location, quality, severity and/or context of complaint.] (Only include if explicitly mentioned...)
[List anything that worsens or alleviates symptoms, including self-treatment attempts and their effectiveness.] (Only include if explicitly mentioned...)
[Progression: how symptoms have changed over time.] (Only include if explicitly mentioned...)
[Previous episodes: past occurrences of similar symptoms, how managed, outcomes.] (Only include if explicitly mentioned...)
[Impact on daily activities, including work and lifestyle.] (Only include if explicitly mentioned...)
[Associated symptoms: other relevant systemic or focal symptoms.] (Only include if explicitly mentioned...)
Objective:
[Vitals] (Only include if explicitly mentioned...)
[Physical examination findings: dermatological exam including inspection/palpation of skin, hair, nails, description of lesions, rashes, distribution, dermoscopy findings.] (Only include if explicitly mentioned...)
[Dermoscopy examination of suspicious moles or lesions, if performed.] (Only include if explicitly mentioned...)
Assessment:
(Never use bullet points to write the assessment section below. Use full sentences and paragraph format.)
[1. Dermatological Issue or Condition, with diagnosis and treatment as specified above.] (Only include if explicitly mentioned...)
[Lifestyle modifications, including skincare advice, sun protection, avoidance of triggers.] (Only include if explicitly mentioned...)
[Follow-up appointments and timeline for review.] (Only include if explicitly mentioned...)
[Referrals] (Only include if explicitly mentioned...)
[2. Additional Dermatological Issues or Conditions, structured as above.] (Only include if explicitly mentioned...)
Management Plan as above:
[Treatment, short summary of the Treatment section.] (Only include if explicitly mentioned...)
[Other actions such as counseling, referrals, lifestyle recommendations.] (Only include if explicitly mentioned...)
Additional Notes:
[Patient education: condition explanation, skincare advice, complications, adherence importance.] (Only include if explicitly mentioned...)
[Instructions for self-examination of skin/moles and red flags.] (Only include if explicitly mentioned...)
[Specific patient/family concerns addressed.] (Only include if explicitly mentioned...)
Next Steps:
[Specific follow-up steps discussed, e.g., scheduling an appointment, starting medication, monitoring symptoms.] (Only include if explicitly mentioned...)
[Actions to take if certain symptoms arise, such as calling the office or seeking urgent care.] (Only include if explicitly mentioned...)
I would recommend www.bad.org.uk and dermnetnz.org for information on the above.
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes or clinical note as a reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
