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Acne
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Discussed pathogenesis/tx options
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BP/clinda/sulfur soap
• • •
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Retinoid
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Doxycycline
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Doxycycline
• • •
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Minocycline
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Minocycline dose
• • •
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Accutane
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Accutane dose
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Check bloodwork
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Extractions
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# lesions injected
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Blue/red light
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Other acne treatment/comments
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Acrochordons
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type of skin tag removal
• • •
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Actinic keratoses
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Discussed treatment options
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LN2 1-14
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number of lesions treated
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LN2 >15
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number of lesions treated
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Efudex
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PDT
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Patient to schedule future PDT
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Future PDT sites
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No history of HSV
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+ h/o HSV
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antiviral dose
• • •
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PDT face today
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IPL settings/number of passes
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Blue light amount of time
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PDT neck and chest today
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IPL settings/number of passes
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Blue light amount of time
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PDT arms & hands today
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IPL settings and number of passes
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Blue light amount of time
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PDT scalp
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IPL settings and number of passes
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Blue light amount of time
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Levulan lot number/expiration
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Total number of sticks used
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other comments
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Alopecia areata
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ILK dose
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Topical treatment
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Atopic dermatitis
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moisturize, avoid triggers
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Topical steroid
• • •
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Non- steroidal
• • •
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Antihistamine
• • •
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Antibiotic
• • •
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Bleach baths
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UV
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other comments/treatments
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Benign nevi
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other comments/treatments
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Botox
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Risks of Neurotoxin Statement
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Consent Form Signed
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Glabella
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Units
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Forehead
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Units
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Crows feet
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Units
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Other (additional area)
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Botox diagram
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Post procedure bruising
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Lot #
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Expiration
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Cherry angiomas
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# of lesions treated
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other comments/treatments
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Filler
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Risks of Filler Statement
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Consent Form Signed
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Consent Form Signed
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Type of anesthetic
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Anesthetic
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Filler #1
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Number of syringes/areas treated
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Lot / Expiration Date
/
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Filler #2
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Number of syringes/areas treated
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Lot / Expiration Date
/
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Filler #3
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Number of syringes/areas treated
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Lot / Expiration Date
/
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Complications
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Complications details
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HSV
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site
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Antiviral
• • •
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Keloid(s)
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2.5mg/cc ILK
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# of cc
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# of lesions
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5 mg/cc ILK
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# of cc
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# of lesions
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10 mg/cc ILK
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# of cc
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# of lesions
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20 mg/cc ILK
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# of cc
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# of lesions
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40 mg/cc
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# of cc
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# of lesions
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ILK/5FU
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# of cc
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# of lesions
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Keratosis pilaris
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Treatment
• • •
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other comments
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Lichen planus
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Topical steroid
• • •
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Melanoma (history of)
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other comments
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no recurrence/lymphadenopathy
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other comments
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Melasma
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Bleaching cream
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Chemical peel
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Type of peel
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No history of HSV
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+ h/o HSV
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antiviral dose
• • •
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IPL
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IPL settings
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No history of HSV
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+ h/o HSV
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antiviral dose
• • •
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Other comments
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Molluscum contagiosum
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Treatment
• • •
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# of lesions treated
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other comments/treatments
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Neoplasm of uncertain behavior
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Consent
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Anesthetic
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Site A
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location
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Ddx
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biopsy type
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hemostasis
• • •
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Site B
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location
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Ddx
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biopsy type
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hemostasis
• • •
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Site C
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location
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Ddx
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biopsy type
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hemostasis
• • •
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Site D
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location
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Ddx
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biopsy type
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hemostasis
• • •
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Site E
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location
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Ddx
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biopsy type
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hemostasis
• • •
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Site F
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location
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Ddx
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biopsy type
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hemostasis
• • •
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Site G
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location
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Ddx
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biopsy type
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hemostasis
• • •
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ointment/bandaid applied
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Plantar Wart
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Dest 1-14 treatment method
• • •
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Dest >15 treatment method
• • •
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Total # treated
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New Field
|
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Psoriasis
|
discussed condition/treatment options
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Topicals
• • •
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Soaps, shampoos
• • •
|
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other comments/treatments
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Rosacea
|
discussed condition/tx options
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New Field
|
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Sebaceous hyperplasia
|
# of lesions treated
|
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type of removal
• • •
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Seborrheic Keratoses
|
# of ISKs treated
|
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# of cosmetic SKs treated
|
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type of removal
• • •
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Tinea corporis
|
other comments/treatments
|
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Tinea versicolor
|
New Field
• • •
|
|
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Other comments
|
|
Varicose veins
|
Sclerotherapy
|
|
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Sclerosing solution used/amount
|
|
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Other comments
|
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Verruca vulgaris
|
Dest 1-14 treatment method
• • •
|
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Dest >15 treatment method
• • •
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Total # treated
|
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New Field
|
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Vitiligo
|
discussed dx/tx options
|
|
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tx
• • •
|
|
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other comments/treatments
|
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Additional free text
|
|
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Discussed Potential side effects of rx / tx.
|
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Discussed Plan with Patient / Primary Caretaker
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D/C meds if pregnant or if develop unusual sx
|
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Discussed Potential drug interactions
|
Sun protection / skin cancer education provided
|
|
Call clinic with any questions or concerns
|
Follow up
|
|
Judicious use of topical steroids/ possible SE
|
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