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Free dermatology note generator
Turn quick skin-check notes into a structured dermatology note, with each lesion described by site, size and morphology and your dermoscopy findings kept as written.
How to use it
- 01
Paste the history
Duration, change over time, symptoms, skin type, sun exposure, and personal or family history of skin cancer.
- 02
Describe the lesion
Exact site, size in mm, morphology, colour and border, plus dermoscopy findings in your usual terms.
- 03
Add assessment and plan
Your impression and what happens next: biopsy, excision, treatment, monitoring or photo follow-up.
What goes in a dermatology note?
A dermatology note has to let another clinician picture the lesion without seeing it. That means a precise site, a measured size and standard morphological terms, with dermoscopy recorded separately from what is seen with the naked eye. The same structure works for a single lesion check, a rash or a full skin examination.
- History
- Duration and evolution of the lesion or rash, symptoms such as itch or bleeding, skin type, sun exposure and relevant personal and family history.
- Lesion description
- Anatomical site, size in millimetres, primary morphology (macule, papule, plaque, nodule), colour, border and surface, plus relevant findings elsewhere on the skin.
- Dermoscopy
- Dermoscopic structures and patterns observed.
- Assessment
- Your clinical impression and differentials, with your level of suspicion.
- Plan
- Biopsy or excision with margins, treatment, photography, advice and follow-up.
Dermatology note example: changing pigmented lesion
History
56-year-old man with a mole on the left upper back that his wife noticed changing over 3 months, becoming darker and larger. Occasionally itchy, no bleeding. Previous basal cell carcinoma of the nose, excised in 2019. Fitzpatrick skin type II, many sunburns in childhood, works outdoors. No family history of melanoma.
Lesion description
Left scapula: 9 × 7 mm asymmetric pigmented macule with an irregular border, two shades of brown and a blue-grey area. Full skin examination: about 40 other naevi, unremarkable. No palpable axillary lymph nodes.
Dermoscopy
Atypical pigment network, irregular dots and globules at the periphery, and focal blue-white structures.
Assessment
Pigmented lesion on the left scapula suspicious for melanoma.
Plan
Urgent excision biopsy with 2 mm margins. Clinical photograph taken. Sun protection advice given. Follow-up with histology result.
Need the diagnosis code too? Search ICD-10-CM codes
Tips for dermatology notes
- Give the site precisely enough to find the lesion again (“left scapula, 5 cm lateral to the spine”), or use a body map.
- Measure lesions in millimetres in two dimensions instead of comparing them to objects.
- Use standard morphology terms (macule, papule, plaque, nodule) and describe colour, border and surface separately.
- Record dermoscopy findings separately from the naked-eye description, using the structures you actually saw.
- Take and reference clinical and dermoscopic photographs so change can be compared at follow-up.
- For excisions, note the margins and how the histology result will be followed up.
Frequently asked questions
Can I describe several lesions in one note?
Yes. Number or label each lesion in your notes with its site; the draft keeps them apart under each heading.
Does it work for rashes and inflammatory skin disease?
Yes. Describe distribution, morphology and extent instead of a single lesion, and write “not done” for dermoscopy if you did not use it.
Will it interpret my dermoscopy findings?
No. It records the structures you describe and the assessment you wrote. It does not add a diagnosis or level of suspicion.
Is it free?
Yes. You can write up to 10 notes a day without an account.
Is it safe to paste patient information?
Paste clinical details only, never names, ID numbers or contact details. The text is sent to our AI provider to write the note and is not saved by Docdemic.