Dermatology · Templates

Dermatology consult template

Use this dermatology consult template in Wavo when morphology, distribution, differentials, and procedural findings need to be documented with specialty-level clarity.

Template content

Copy or download, then paste into Wavo under My Templates.

Dermatology Consultation Note

Chief Complaint
- Primary skin concern and duration.

History of Present Illness
- Onset, evolution, symptoms (pruritus, pain, burning, bleeding), triggers, and seasonal/occupational factors.
- Distribution and spread pattern; prior self-treatments and prescription therapies with response.
- Systemic symptoms if relevant (fever, arthralgias, weight loss).
- Sun exposure, tanning bed use, skin cancer history, and family history of melanoma/atopy as relevant.

Medications / Allergies / Relevant History
- Current topicals and systemics; drug allergies; atopic, autoimmune, or immunosuppression history.

Exam
- Skin type/Fitzpatrick if documented; morphology (macule, papule, plaque, vesicle, pustule, nodule, ulcer), color, size, border, scale/crust, and configuration.
- Distribution/body sites examined (including scalp, nails, mucosa if assessed).
- Full-skin exam findings if performed; suspicious lesion descriptors (ABCDE).

Procedures Today
- Biopsy type/site, cryotherapy, ED&C, excision, injection, or dermoscopy findings with consent as applicable.

Assessment
- Dermatologic diagnosis/differential with brief reasoning.

Plan
- Topical/systemic therapy with application instructions and expected course.
- Wound care, activity/sun precautions, pathology pending language, and follow-up timing.

When to use this template

What makes the structure useful, and which visits it fits best.

Why this template works

Structural advantages for real documentation

Best for

Visit types and clinicians who use this format

  • Prioritizes morphology and distribution—the language dermatology notes depend on.
  • Supports medical derm and procedural/biopsy documentation in one flow.
  • Captures prior therapies and response without burying the assessment.
  • Easy to adapt for teledermatology with photo-review language.
  • 1New outpatient dermatology consultations
  • 2Rash and lesion evaluations
  • 3Biopsy and procedure-inclusive new visits

Example output shape

Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.

Chief Complaint
Itchy rash on arms and trunk for 5 weeks.

HPI
Began as pink patches on antecubital fossae, spread to flanks. Severe pruritus, worse at night. OTC 1% hydrocortisone minimal help. No new meds, fevers, or joint pain. History of childhood eczema; flares with stress.

Exam
Fitzpatrick II. Ill-defined erythematous plaques with fine scale in antecubital fossae, posterior neck, and flanks (~8% BSA). No vesicles, purpura, or mucosal involvement. Nails without pitting.

Procedures
None today. Dermoscopy of two truncal lesions: no melanocytic concern.

Assessment
Moderate atopic dermatitis flare; rule out contact dermatitis overlay.

Plan
Triamcinolone 0.1% ointment BID to body × 2 weeks then weekends only. Cetaphil cleanser; plain petrolatum BID. Avoid fragrance products. Non-sedating antihistamine PRN itch. RTC 6 weeks or sooner if spreading/infection signs; discuss dupilumab if refractory.

How Wavo automates this

What the product actually does with your template.

1. Add the template

Paste this content into My Templates, or start from a specialty-generated template and edit the sections.

2. Record or dictate

Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.

3. Review and sign

Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.

Put this template to work on your next visit

Start free, paste the template, and see how Wavo documents in your structure.