A dermatology procedure note template that sets out what belongs in each section, ready to adapt to your own clinic.
01Procedure note
TemplateDermatology
Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]
Dermatology procedure note, punch biopsy
1Indication
The lesion, its location and why histology is needed.
2Consent
How consent was taken, and the risks, benefits and alternatives discussed.
Whether written consent is on the record, with its date.
3Procedure
Site, method and closure, with the specimen labelled at the bedside.
Patient identity and site confirmed and marked before starting.
4Findings
Specimen sent, the laboratory and the pathway for the result.
5Complications
Any complication, or a record that there were none.
Anything that did not go to plan, and what was done about it.
6Aftercare and follow-up
Aftercare advice given, verbally and in writing.
Follow-up arranged, and what should prompt the patient to get in touch sooner.
How the Wai scribe fills it
The same note, written from an invented consultation.
Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.
01Procedure note
SignedAI-assisted, edited by the clinician
Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person
Dermatology procedure note
1Indication
Changing pigmented lesion, left upper back. Histology required.00:45
2Consent
Completed by the clinician from the record.
3Procedure
Local anaesthetic infiltrated. 4 mm punch biopsy taken. Site and identity confirmed before starting.04:00
4Findings
Specimen labelled at the bedside and sent to [laboratory].07:10
5Complications
Completed by the clinician from the record.
6Aftercare and follow-up
Dressing for 24 hours. Suture removal in ten days. Wound care leaflet given.08:00
Questions
What goes in a dermatology procedure note?
Indication, Consent, Procedure, Findings, Complications and Aftercare and follow-up. Each section on this page lists what belongs in it, written for dermatology.
Is the worked example a real patient?
No. The consultation is invented for this page, and no real patient or record is used.
Does the scribe sign the note?
No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.
Can we use our own note structure?
Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.
