Dermatologist Template
Full Skin Examination
A professional Dermatologist template for healthcare professionals.
About this template
This Full Skin Examination template is designed for dermatologists to document comprehensive skin assessments. It includes sections for current concerns, detailed examination findings across various body parts, and a plan for treatment and follow-up. Dermatologists can use this template to ensure thorough documentation of skin conditions, aiding in accurate diagnosis and treatment planning. The template also allows for the inclusion of relevant ICD-10 codes, streamlining the billing process.
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Full Skin Examination
Current Concerns:
- Patient reports a persistent rash on the lower back and occasional itching on the scalp.
Examination:
- Face: No lesions or pigmentation changes observed.
- Ears: No abnormal findings.
- Scalp: Mild scaling observed, no alopecia.
- Neck: No lesions or lumps detected.
- Chest: No rashes or pigmentation changes.
- Abdomen: No abnormal findings.
- Upper limbs: No lesions or rashes.
- Hands: No nail changes or rashes.
- Lower limbs: No varicosities or pigmentation changes.
- Feet: No lesions or nail changes.
- Buttocks: No rashes observed.
- Back: Mild erythematous rash on the lower back.
Plan:
- Prescribe topical corticosteroid for the rash on the lower back.
- Recommend medicated shampoo for scalp scaling.
- Follow-up appointment in 4 weeks to assess treatment efficacy.
Billing:
- ICD-10 Code L30.9 for unspecified dermatitis
- ICD-10 Code L21.0 for seborrheic dermatitis of the scalp
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Specialty
Dermatologist
Used
153 times
Type
Note
Last edited
9/6/2024
Created by
Glenda Schoombee