Dermatology Outpatient Clinical Note

Chief Complaint: [Patient's gender and age] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.) [Patient's primary dermatologic complaint] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as a full sentence, as its own paragraph.) History Of Present Illness: [A detailed chronological account of the dermatologic complaint including onset, duration, location, evolution, morphology, colour, size, distribution, configuration, associated symptoms such as pruritus, pain or bleeding, aggravating and alleviating factors, and previous treatments tried] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences in paragraph format.) Past Medical History: [Significant past dermatologic conditions, history of skin cancer, surgeries, hospitalisations, and any other relevant past medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Medications: [Current medications including topical and systemic treatments for skin conditions with dosages and frequencies where stated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each medication as a separate bullet point.) Allergies: [Known drug allergies and reactions including any history of contact dermatitis or other skin-related allergic reactions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each allergy as a separate bullet point.) Social History: [Relevant social history including tobacco use, alcohol consumption, recreational drug use, occupation, and living situation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Family History: [Family history of skin conditions including skin cancer, melanoma, psoriasis, atopic dermatitis, or other relevant hereditary dermatoses, including conditions explicitly denied] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each condition as a separate bullet point, noting whether each was confirmed or denied.) Review Of Systems: [A systematic review of relevant organ systems] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences in paragraph format, or as bullet points depending on how the information is presented in the transcript.) Physical Examination: [Vital signs and physical examination findings organised by body system] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each body system as a separate paragraph.) Assessment: [The clinician's explicitly stated clinical impression and differential diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write in full sentences in paragraph format.) Plan: [Diagnostic tests, treatments, medications, and follow-up recommendations as stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point. If emollients are mentioned in the plan, include the following statements exactly as written: "Apply generously twice a day." "Allow to soak in and avoid rubbing." "Apply after showering." "Wait 30 minutes before applying any steroid cream." and include the emollient patient information leaflet link as a placeholder: [Link to emollient use in skin conditions patient information leaflet]. If steroid creams are mentioned in the plan, document that a fingertip unit explanation was provided and a fingertip unit leaflet was given, and include the steroid cream patient information leaflet link as a placeholder: [Link to topical corticosteroids patient information leaflet]. If Efudix or Tolak cream is mentioned in the plan, include the following statements exactly as written: "Apply thinly to affected areas, wash hands after use, and avoid mucosal membranes." "Wash off after 8 hours." "Apply suncream and avoid high UV and mid-day sun." "Side effects may include redness and tenderness to the site of application." and include the following patient information leaflet links as placeholders: [Link to 5-fluorouracil cream patient information leaflet] and [Link to Efudix cream for actinic keratoses patient information leaflet].)