AI scribe for dermatology

DERMATOLOGY — SKIN EXAM
Date: [date] | Visit reason: [concern]

HISTORY
Patient concern: [in their words]
Onset and changes: [duration, evolution, symptoms]
Relevant history: [provided context]

EXAMINATION BY SITE
Exam scope: [areas examined]
Finding: [site, laterality, size, morphology]
Additional findings: [repeat by site as needed]

ASSESSMENT
Clinician assessment: [documented impression by concern]
Discussion: [options and patient questions]

PLAN AND FOLLOW-UP
Agreed plan: [documented decisions]
Patient instructions: [as discussed]
Next contact: [timing, owner, outstanding items]

DERMATOLOGY — SKIN EXAM
Completed example
Date: 9 September 2026 | Visit reason: Left forearm lesion

HISTORY
Patient concern: “This spot on my left forearm has been here for three months.”
Onset and changes: Present for three months; intermittently catches on clothing. No bleeding reported.
Relevant history: Patient brought a timeline of the changes they noticed.

EXAMINATION BY SITE
Exam scope: Focused examination of the left forearm.
Finding: Left dorsal forearm, 6 mm pink, scaly papule.
Additional context: Patient’s timeline included with the visit notes.

ASSESSMENT
Clinician summary: Left forearm finding documented with its size and appearance.
Discussion: Changes noticed by the patient and questions about the next appointment discussed.

PLAN AND FOLLOW-UP
Agreed plan: Send the patient a summary of today’s discussion.
Patient summary: Include the skin concern, observations, and agreed next steps.
Next contact: Clinic coordinator to arrange the follow-up appointment.

DERMATOLOGY — CONSULTATION
Date: [date] | Visit reason: [concern]

REFERRAL CONTEXT
Referral source: [clinician or service]
Reason for visit: [referral question]
Available context: [letter, records, patient notes]

PATIENT PRIORITIES
Main question: [in the patient’s words]
Background: [relevant history]
Topics to cover: [visit agenda]

VISIT DISCUSSION
Summary: [topics discussed]
Questions addressed: [questions and responses]
Patient preference: [format for the visit summary]

SUMMARY AND NEXT STEPS
Visit summary: [key points]
Coordination: [recipient and document]
Next contact: [owner and timing]

DERMATOLOGY — CONSULTATION
Completed example
Date: 9 September 2026 | Visit reason: Skin concerns

REFERRAL CONTEXT
Referral source: Patient’s family doctor.
Reason for visit: Discuss recent skin changes and the patient’s questions.
Available context: Referral letter and patient’s written timeline.

PATIENT PRIORITIES
Main question: “What should I include when I describe the changes I’ve noticed?”
Background: Patient brought a list of questions to the appointment.
Topics to cover: Timing of changes, affected areas, and follow-up arrangements.

VISIT DISCUSSION
Summary: Referral context and patient’s observations discussed together.
Questions addressed: What information to include in future visit updates.
Patient preference: A written summary of today’s conversation.

SUMMARY AND NEXT STEPS
Visit summary: Include the patient’s priorities and the topics discussed.
Coordination: Send a consultation summary to the referring clinician.
Next contact: Clinic team to arrange the next appointment.

DERMATOLOGY — FOLLOW-UP
Date: [date] | Previous visit: [date]
Concern: [condition or site being followed]

INTERVAL HISTORY
Patient update: [symptoms and changes]
Current routine: [patient-reported use and concerns]
Results reviewed: [source, date, discussion if applicable]

CURRENT FINDINGS
Exam format and scope: [in person / virtual]
Site and morphology: [observed findings]
Change from prior visit: [documented comparison]

ASSESSMENT AND DISCUSSION
Clinician assessment: [documented impression]
Patient questions: [questions and discussion]

PLAN AND NEXT CONTACT
Agreed plan: [continue / change as discussed]
Patient instructions: [reviewed guidance]
Follow-up: [timing, owner, open items]

DERMATOLOGY — FOLLOW-UP
Completed example
Date: 9 September 2026 | Previous visit: 29 July 2026
Concern: Bilateral hand dermatitis

INTERVAL HISTORY
Patient update: Less itching since the previous visit; dryness returns after work.
Current routine: Patient reports using the previously discussed skin-care routine and asks how to keep it consistent during the workday.
Results reviewed: No new investigation results reviewed at this visit.

CURRENT FINDINGS
Exam format and scope: In-person, focused examination of both hands.
Site and morphology: Dry, scaly patches over the dorsal surfaces of both hands.
Change from prior visit: Patient-reported itching improved; dryness persists.

ASSESSMENT AND DISCUSSION
Clinician assessment: Hand dermatitis with improvement in reported itching and persistent dryness.
Patient questions: Workday skin-care routine discussed; patient’s questions addressed.

PLAN AND NEXT CONTACT
Agreed plan: Send a written summary of the skin-care routine discussed.
Patient instructions: Written summary of the routine reviewed during the visit to be provided.
Follow-up: Next conversation in six weeks; clinic team to arrange the appointment.