Dermatology follow-up
United States | Dermatology

Blank documentation outlines for US practice. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

ENCOUNTER
Patient name: [ ]
Date of birth: [ ]
Date and time of encounter: [ ]
Clinician: [ ]

INTERVAL HISTORY
Condition addressed: [ ]
Symptoms, distribution and change since last visit: [ ]
Treatment used, adherence, response and adverse effects: [ ]
Impact on daily activities and patient goals: [ ]

EXAMINATION AND RESULTS
Areas examined and current findings: [ ]
Comparison with documented prior findings: [ ]
Tests or monitoring reviewed with dates: [ ]

ASSESSMENT AND PLAN
Current status and clinical reasoning: [ ]
Continue, change or stop treatment decisions: [ ]
Medication counseling and monitoring discussed: [ ]
Patient preferences: [ ]

FOLLOW-UP
Follow-up timing and purpose: [ ]
Return precautions discussed: [ ]
Patient questions and understanding: [ ]