Skin examination
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: [ ]

HISTORY
Patient concerns and changing lesions: [ ]
Personal and family skin cancer history as reported: [ ]
Relevant exposures and prior treatments: [ ]
Medications and allergies reviewed: [ ]

EXAMINATION
Extent of examination and areas deferred or declined: [ ]
Chaperone discussion and presence if applicable: [ ]
Findings by anatomic site and laterality: [ ]
Lesion dimensions, morphology and dermoscopic findings if assessed: [ ]
Photographs obtained and consent if applicable: [ ]

ASSESSMENT AND PLAN
Problem or lesion, clinical impression and differential: [ ]
Management options and decisions: [ ]
Procedures actually performed or planned: [ ]
Counseling provided: [ ]

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