Skin lesion assessment
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: [ ]

LESION HISTORY
Site and laterality: [ ]
Duration, change and associated symptoms: [ ]
Prior treatment and relevant risk history: [ ]

FINDINGS
Location, dimensions and morphology: [ ]
Examination and dermoscopy findings if performed: [ ]
Photograph or body-map reference if obtained: [ ]

ASSESSMENT
Clinical impression and differential: [ ]
Reasoning for observation, treatment or tissue sampling: [ ]

PLAN AND PROCEDURES
Options and consent discussion: [ ]
Procedure details if performed, including site verification and anesthetic used: [ ]
Specimen label, destination and requested test if collected: [ ]
Aftercare and result communication plan: [ ]
Clinician responsible for reviewing results: [ ]

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