Clinical notes
Dermatology Consult Note Template: Morphology, Diagnosis, and Plan
Dermatology is a visual specialty, and the note has to prove you looked: morphology, distribution, and lesion characteristics before diagnosis. This template follows Scribeberry's built-in Dermatology Consult, used by clinicians for rashes, lesions, and skin cancer follow-up.
Dermatology Consult Note Template: Morphology, Diagnosis, and Plan
Ready to review- Visit details pulled in
- Letter drafted from the conversation
- Your review and signature
Key takeaways
- A dermatology consult note describes morphology, size, distribution, and dermoscopy before it names a diagnosis.
- Precise lesion location and measurement are what make surveillance and later comparison possible.
- Treatment documented by category — topical, systemic, procedure, phototherapy — keeps monitoring obligations visible.
What is a dermatology consult note?
A dermatology consult note is a written document that records a specialist skin assessment: the history of the present dermatological symptoms, past dermatological history, a morphology-first description of lesions, biopsy and pathology results where available, a dermatological diagnosis, and a treatment plan covering topicals, systemics, procedures, and phototherapy. A dermatology consult template enforces the specialty's discipline — describe before you diagnose — so the record supports both care and any later review.
The template below matches Scribeberry's built-in Dermatology Consult, one of the most-used specialty templates in Scribeberry. Sections with no information are marked Not Provided rather than filled by assumption.
Blank dermatology consult note template
Copy this structure into your EMR, or use it as the Dermatology Consult inside Scribeberry, where it fills in from the encounter itself.
Dermatology consult note
Chief Complaint (CC) History of Present Dermatological Symptoms (HPDS) Past Medical and Dermatological History (PMDH) Medications Allergies Family History Review of Systems (ROS) Dermatological Examination Findings Skin Lesions and Characteristics Skin Biopsy and Pathology Results Dermatological Diagnosis Treatment Plan Topical and Systemic Medications Surgical Interventions Phototherapy or Other Procedures Patient Education on Skin Care Prognosis Follow-up Plan Consultation Recommendations (if applicable) Referral Recommendations (if applicable)
Example 1: Pigmented lesion assessment
Dermatology consult example — changing mole
Fictional example for illustration only. 52-year-old referred for a changing pigmented lesion on the back.
Chief complaint: 'This mole has changed over the past year.' History of present dermatological symptoms: Lesion on mid-back present for years, darkened and enlarged over ~12 months. Occasional itch, no bleeding or ulceration. No similar changing lesions. Significant recreational sun exposure; outdoor occupation in youth. No prior skin cancers. Family history: father with melanoma at 60. Dermatological examination: Skin phototype II. Multiple benign-appearing melanocytic nevi on trunk. Index lesion: 9 mm asymmetric pigmented plaque on the left mid-back with irregular borders and colour variegation (tan, dark brown, black focus). Dermoscopy: atypical network, irregular globules, blue-white veil. No palpable lymphadenopathy. Skin lesions and characteristics: Single atypical pigmented lesion as described; background nevi banal. Biopsy: Excisional biopsy performed today (see procedure note); specimen to pathology. Dermatological diagnosis: Atypical pigmented lesion — rule out melanoma in situ / invasive melanoma pending pathology. Treatment plan: Wound care instructions given; suture removal 10–14 days. Results by phone within 2 weeks with expedited follow-up if malignant. Patient education on skin care: daily broad-spectrum SPF 50, protective clothing, monthly self-examination, and photographs for monitoring. Prognosis: Pending histology. Follow-up: 2 weeks, or sooner if pathology returns malignant.
Example 2: Chronic plaque psoriasis review
Second example — psoriasis not controlled on topicals
Fictional example for illustration only. 44-year-old with 8 years of plaque psoriasis, referred for escalation.
Chief complaint: Psoriasis flare, topicals no longer enough. HPDS: Well-demarcated erythematous plaques with silvery scale on elbows, knees, scalp, and lower back, ~8% body surface area. Itch 6/10, sleep disturbed. Nail pitting present. No joint pain or morning stiffness. Triggers: winter, stress. Failed: high-potency topical corticosteroid + vitamin D analogue with good adherence. Past dermatological history: No prior phototherapy or systemics. No skin infections. Examination: Plaques as described; BSA 8%, PASI estimated moderate-severe. Nails: pitting and oil spots. No synovitis on screening exam. Diagnosis: Chronic plaque psoriasis, moderate-to-severe, inadequate response to topicals. Treatment plan: Options discussed — phototherapy vs systemic therapy. Patient prefers systemic; baseline labs, TB and hepatitis screening ordered, vaccinations reviewed. Patient education: emollients daily, trigger management, cardiovascular risk counselling (psoriasis-associated). Phototherapy booked as bridge. Follow-up 4 weeks with lab results; joint symptom review at every visit for psoriatic arthritis surveillance.
How to write a dermatology consult note, step by step
- Take the symptom history like a dermatologist: onset, evolution, itch vs pain, triggers, prior treatments and response.
- Record past dermatological history, skin cancer history, and family history of melanoma or psoriasis.
- Describe before diagnosing: morphology (macule, papule, plaque, vesicle), colour, size, surface, and distribution.
- Add dermoscopic findings for pigmented lesions and document lesion measurements.
- Record biopsy and pathology results, or the plan to obtain them, in their own section.
- State the dermatological diagnosis, with the differential where histology is pending.
- Split treatment into topicals, systemics, procedures, and phototherapy so nothing is buried.
- Close with skin-care education, prognosis, and a dated follow-up tied to results.
Describing lesions: morphology terms that carry the note
| Term | Meaning | Typical use |
|---|---|---|
| Macule / patch | Flat colour change, <1 cm / ≥1 cm | Vitiligo, melasma |
| Papule / plaque | Raised solid lesion, <1 cm / ≥1 cm | Psoriasis, lichen planus |
| Nodule | Deeper solid lesion ≥1 cm | Dermatofibroma, BCC |
| Vesicle / bulla | Fluid-filled, <1 cm / ≥1 cm | Herpes, bullous pemphigoid |
| Pustule | Pus-filled lesion | Pustular psoriasis, folliculitis |
| Scale / crust | Surface keratin / dried exudate | Eczema, impetigo |
Who uses a dermatology consult note, and when
Dermatologists, family physicians with focused skin practices, and nurse practitioners write dermatology consult notes in referral clinics, primary care, and teledermatology.
- Pigmented-lesion and skin-cancer assessments.
- Inflammatory disease reviews (eczema, psoriasis) failing first-line therapy.
- Rash referrals where morphology will decide the differential.
- Procedure-linked visits: biopsies, excisions, cryotherapy.
- Teledermatology reviews based on submitted images.
Documentation, privacy, and record-keeping in Canada
Dermatology notes are frequently reviewed later — when a lesion proves malignant, when photographs are compared, or when treatment is escalated to systemics with monitoring obligations. Morphology, measurements, dermoscopy, and body location must be precise enough for another clinician to find and compare the same lesion months later. Document consent for clinical photography and where images are stored; in Canada those images form part of the health record under provincial privacy law.
Across Canada, clinical notes form part of the legal medical record. Provincial regulators expect entries that are contemporaneous, factual, and attributable; health information is handled under provincial privacy law (such as PHIPA in Ontario, the HIA in Alberta, and Law 25 in Quebec) and PIPEDA where it applies. Disclose the minimum necessary, with patient consent, and record amendments as amendments — never by overwriting the original entry.
Common mistakes that weaken a dermatology consult note
- Jumping to a diagnosis with no morphology description.
- No size measurement or anatomical landmark for a lesion under surveillance.
- Dermoscopy performed but findings not recorded for pigmented lesions.
- Biopsy site not described precisely enough to re-identify.
- Systemic therapy started with no baseline labs, screening, or monitoring plan.
- 'Reassured' recorded for a changing lesion with no follow-up interval or safety net.
The signing checklist
Before signing: Is the reason for the encounter explicit? Are negatives that change management recorded? Does every diagnosis have a plan with an owner and a date? Are results, counselling, and follow-up documented — or only intended?
Using this template in Scribeberry
Describe it once — the note keeps the morphology
Choose Dermatology Consult in Scribeberry and your dictated morphology, dermoscopy, and plan land in the right sections. Then Smart Push the note into your EMR and move to the next patient.
Frequently asked questions
What should a dermatology consult note include?
Chief complaint, history of present dermatological symptoms, past dermatological history, medications and allergies, a morphology-first examination with lesion characteristics, biopsy/pathology results, diagnosis, treatment plan split by topicals/systemics/procedures, education, prognosis, and follow-up.
Why describe morphology before diagnosis?
The description is the verifiable record. If the diagnosis is later questioned, accurate morphology (type, size, colour, distribution, dermoscopy) lets another clinician reconstruct the reasoning — a diagnosis alone does not.
What dermoscopy findings should be documented?
For pigmented lesions: network pattern, globules, streaks, blue-white veil, vascular pattern, and any melanoma-specific structures, plus the lesion's measured size and location.
Can Scribeberry generate this note automatically?
Yes. The built-in Dermatology Consult template follows this exact structure and drafts it from the recorded or dictated encounter, marking missing information as Not Provided instead of inventing it.
Why do dermatologists describe before diagnosing?
The description is the verifiable evidence. Morphology, size, distribution, and dermoscopy let any later clinician reconstruct the reasoning and compare change over time.
Are clinical photographs part of the legal record?
Yes. With consent documented, photographs are part of the health record and should be stored, labelled with date and site, and handled under the same privacy rules as the note.
References
- Good practices in medical record keeping — Canadian Medical Protective Association (CMPA)
- Medical Records Documentation — practice standard — College of Physicians and Surgeons of Ontario (CPSO)
- Personal Health Information Protection Act (PHIPA) — Government of Ontario
- Skin health resources — Canadian Dermatology Association
- Skin cancer information — Canadian Cancer Society
Examples on this page are fictional and for illustration only; they do not describe real patients. Templates reflect the corresponding built-in template in Scribeberry at the date above.
