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General Practitioner Template

Dermoscopy

A professional General Practitioner template for healthcare professionals.
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About this template

Need a clear and concise way to document skin lesion assessments? This Dermoscopy template is perfect for General Practitioners. It helps you systematically record patient history, examination findings, and your management plan. This template guides you through describing the lesion's site, size, shape, border, colour, and surface, as well as dermoscopic features. With Heidi, this template can be quickly populated from your consultation transcript, saving you time and ensuring comprehensive documentation. This template will help you create detailed clinical notes, ensuring accurate and efficient patient care.

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**History of Presenting Complaint** Patient presents with a pigmented lesion on their back that they noticed approximately 6 months ago. It has been slowly enlarging and has recently started to itch. No bleeding or crusting has been noted. The patient denies any prior trauma or infection to the area. No prior similar lesions. --- **Relevant Past History** Patient has a family history of melanoma in their mother. --- **Medications & Allergies** Patient is not currently taking any medications and has no known allergies. --- **Examination Findings** **Site:** Posterior trunk, mid-back. **Size:** 6mm. **Shape:** Irregular. **Border:** Irregular, with some fading. **Colour:** Variegated, with shades of brown and black. **Surface:** Smooth. **Dermoscopic features:** Irregular pigment network, some areas of structureless pigmentation. --- **Assessment / Impression** Suspicious pigmented lesion, concerning for possible melanoma. Requires further investigation. --- **Plan** Discussed the findings and level of concern with the patient. Patient was informed of the need for urgent referral to dermatology for excision and further assessment. Provided safety-net advice, including instructions to return if changes in size, shape, colour, or bleeding occur. Patient was given written information about melanoma and the referral process. --- **Follow-up** Patient will be referred to dermatology for further assessment and excision. Awaiting secondary care outcome. Review timeframe is within 2 weeks.
**History of Presenting Complaint** [Summarise patient’s description of the presenting complaint, including duration, changes over time, symptoms (itching, bleeding, crusting, pain), evolution (static/enlarging/changing colour or shape), prior trauma or infection, prior similar lesions, and any previous excision, biopsy, or dermatology input.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) --- **Relevant Past History** [Include relevant history such as melanoma, non-melanoma skin cancer, immunosuppression, significant sun exposure, tanning bed use, or family history of melanoma.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) --- **Medications & Allergies** [List relevant medications and allergies, especially immunosuppressants, photosensitisers, or anticoagulants if considering biopsy.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) --- **Examination Findings** (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Site:** [Describe site of lesion] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Size:** [Record lesion size in mm] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Shape:** [Describe shape — round, irregular, asymmetric] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Border:** [Describe border — well-defined, irregular, fading] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Colour:** [Describe pigmentation pattern — uniform or variegated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Surface:** [Describe surface — smooth, scaly, crusted, ulcerated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Dermoscopic features:** [Describe dermoscopic features such as pigment network, globules, dots, streaks, structureless areas, blue-white veil, regression, vessels, or features suggestive of melanoma, BCC, seborrhoeic keratosis, naevus, etc.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) --- **Assessment / Impression** [Provide a concise summary of the lesion appearance and level of concern, e.g. benign-appearing melanocytic naevus or suspicious pigmented lesion to rule out melanoma.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) --- **Plan** [List management plan as discussed, including reassurance and advice, self-monitoring with photographic record, safety-net advice (return if changes in size, shape, colour, or bleeding occur), 2WW referral for urgent excision, routine referral for dermatology review, cryotherapy or excision in primary care if appropriate, and written information given.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) --- **Follow-up** [State follow-up arrangements, e.g. review timeframe or awaiting secondary care outcome.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) --- (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. 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 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.)
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Specialty

General Practitioner

Used

8 times

Type

Note

Last edited

13/10/2025

Created by

Anonymous

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