Dermatology Consult

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Dermatology Consult

Date/Time: [Insert date and time of consult]

Reason for Consult: [Insert concise reason for dermatology evaluation, who requested the consult, and clinical question]

Patient Identification: [Patient initials or MRN], [age], [gender], with a history of [brief relevant history], presenting with [chief dermatologic concern].

History of Present Illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Begin with onset, duration, progression of skin findings.]

[Mention precipitating or alleviating factors, prior treatments, response to therapy.]

[Review of systems specific to the speciality]

Past Medical History:
(Hyphenated list)

Medications:
(Hyphenated list)
- [Medication name, dose, route, frequency if mentioned]
- [e.g., Metformin 500 mg oral BID]

Allergies:
(Hyphenated list)
(If no known allergies, state exactly “No known drug allergies (NKDA)”)

Family History:
(Hyphenated list)
- [Relative]: [Condition or pertinent finding]
- [e.g., Mother: breast cancer]

Social History:
(Hyphenated list)
- Tobacco: [type, amount, duration, quit date if applicable]
- Alcohol: [type, amount, frequency]
- Recreational substances: [type, frequency]
- Occupation: [current job, exposures]
- Living situation: [who lives with patient, home environment]

Physical Examination:
(hyphenated list)
- Vital signs: HR: __, BP: __, T: __, RR: __, O2 sats: __%
- Skin/general: [Overall skin tone, evidence of systemic involvement]
- Lesion description: [Morphology (macule, papule, plaque, vesicle, etc.), size, color, distribution, configuration, surface changes, secondary changes (excoriations, crusts)]
- Hair/nails/mucous membranes: [Findings]
- Lymph nodes: [Regional lymphadenopathy if present]

Investigations:
(hyphenated list)
- Laboratory tests: [e.g., CBC, CMP, specific serologies]
- Dermatopathology: [Biopsy site, type, pending or result summary]
- Imaging: [If relevant]

Assessment & Plan:
(Use medical terminology if appropriate. Do not fabricate.)
[One-sentence patient summary including age, sex, and primary diagnosis if not redundant]

#) [Assessment as a numbered item] 
- [List plan as ABCDE]
- [Hyphenated list with each corresponding plan item on a new line]

- [Mention need for regular skin care, protection from sun]