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OBJECTIVE
|
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General WNL
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General Abnormal
• • •
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General Comments
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SKIN Inspection
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Integumentary
• • •
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Skin Comments
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Exam performed locations
• • •
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General Appearance
• • •
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Orientation
• • •
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Mood and Affect
• • •
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Exam Notes:
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IMPRESSION / PLAN
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1Assessment
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1Impression
• • •
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1Location
• • •
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1 Enter Counseling Macro here
|
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1PIC1.2
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1PIC1.1
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1PIC1.3
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1PIC1.4
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1Treatment Deferred
|
1No Treatment Reason
• • •
|
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1No tx notes
|
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1PLAN: SHAVE REMOVAL
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1SHAVE CONSENT
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1# of ML Lidocaine
|
1SHAVE - Location
• • •
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1SHAVE- Malignant
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1Shave-Malig- Trunk,Ext
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1SIZE of lesion : Malig- Trunk,Extremity
• • •
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1Shave-Malig- Hand,Foot,Neck.
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1SIZE of lesion : Malig- Hand,Foot,Neck.
• • •
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1Shave-Malig- Face, mm
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1SIZE of lesion : Malig- Face, mm
• • •
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1SHAVE - B9
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1Shave- B9- Trunk-Extremity
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1Shave-B9 Size-Trunk-Extremity
• • •
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1Shave- B9- Hand,Foot,Neck.
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1Shave-B9-Size- Hand,Foot,Neck.
• • •
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1Shave- B9- face- mm
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1Shave-B9-Size-face- mm
• • •
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1Hemostasis + closing
• • •
|
1Addl notes
|
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1CRYOSURGERY
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1Cryo Consent
|
|
1Lesion Type & Qty
• • •
|
1# of Frz / Thaw Cycles
• • •
|
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1DESTRUCTION MALIGNANT LESION
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1Destruction Consent
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1Destruction CRYO
|
1LIDO # of ML
|
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1CRYO - Trunk, Arm, Legs
|
1SIZE of lesion : Trunk, Arms, Legs
• • •
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1CRYO - Scalp, Neck, Hands, Feet
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1SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
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1CRYO - Face, Ears, Eyelids, Nose, Lip
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1SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
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1# of Frz / Thaw Cycles
• • •
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1Cryo - BCC
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1cryo - BCC - Loc
• • •
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1Cryo - SCC
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1cryo - SCC - Loc
• • •
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Cryo1 - SCCIS
|
1cryo - SCCIS - Loc
• • •
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1CRYO- ADDL NOTES
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|
1Destruction RF
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1REQUIRED # of ML
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|
1RF - Trunk, Arm, Legs
|
1SIZE of lesion : Trunk, Arms, Legs
• • •
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|
1RF - Scalp, Neck, Hands, Feet
|
1SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
|
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1RF - Face, Ears, Eyelids, Nose, Lip
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1SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
|
|
1# of RF Applications
• • •
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1RF - BCC
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1BCC - location
• • •
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1RF - SCC
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1SCC - Location
• • •
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1RF Notes
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1DNA WOUND SWAB
|
1SWAB location
• • •
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1Addl Notes
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1OTC Tx Regimen
|
1OTC Topicals
• • •
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1Addl Notes
|
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1PRESCRIPTION
|
1Prescriptions
• • •
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1Addl Notes
|
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1.5FU INJECTION
|
1INJECTION SITE
• • •
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|
1Treatment #
|
1Lot #:
|
|
1Expiration Date:
/
|
1Consent Obtained?
|
|
1LESION TYPE
• • •
|
1INJECTION SITE same as above
• • •
|
|
1QTY of MLs
|
1Administering Provider
|
|
1# MLs Lido mixed
|
1Was lido mixed?
|
|
1.5FU Addl Notes
|
|
|
1DermTech Adhesive Biopsy
|
1DermTech Addl Notes
|
|
1Intralesional Kenalog Injection
|
1Consent obtained?
|
|
1. # of lesions injected
|
1Kenalog Lesion Type
• • •
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1INJECTION SITE
• • •
|
1Kenalog ML/volume
• • •
|
|
1Kenalog Type/ concentration
• • •
|
1Qty of lido mixed?
• • •
|
|
1Total volume inj w/ lido
• • •
|
1Lot #
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|
1Expiration Date
/
|
1Administering Provider
|
|
1Kenalog Addl Notes
|
|
|
1 Debridement
|
1Size: L mm x W mm x D mm
|
|
1Blade used
• • •
|
1Drainage Type&Amount
• • •
|
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1Dressing type
• • •
|
1Addl Notes
|
|
1Dressing Change Performed
|
1Dressing change location
• • •
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1Dressing type
• • •
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1Addl Notes
|
|
1Dressing Change Regimen
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1Regimens
• • •
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|
1Dressing type
• • •
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1Addl Notes
|
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2Assessment
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2Impression
• • •
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2Location
• • •
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|
2PIC2.1
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2PIC2.2
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2PIC2.3
|
2PIC2.4
|
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2 Enter Counseling Macro here
|
|
|
2Treatment Deferred
|
2No Treatment Reason
• • •
|
|
2No tx notes
|
|
|
2PLAN: SHAVE REMOVAL
|
2SHAVE CONSENT
|
|
2# of ML Lidocaine
|
SHAVE2 - Location
• • •
|
|
2SHAVE- Malignant
|
|
|
2Shave-Malig- Trunk,Extremity
|
2SIZE of lesion : Malig- Trunk,Extremity
• • •
|
|
2Shave-Malig- Hand,Foot,Neck.
|
2SIZE of lesion : Malig- Hand,Foot,Neck.
• • •
|
|
2Shave-Malig- Face, mm
|
2SIZE of lesion : Malig- Face, mm
• • •
|
|
2SHAVE - B9
|
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2Shave- B9- Trunk-Extremity
|
2Shave- B9 -Trunk-Extremity
• • •
|
|
2Shave- B9- Hand,Foot,Neck.
|
2Shave- B9- Hand,Foot,Neck.
• • •
|
|
2Shave- B9- face- mm
|
2Shave- B9- face- mm
• • •
|
|
2Hemostasis + closing
• • •
|
2Addl notes
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|
2CRYOSURGERY
|
2Cryo Consent
|
|
2Lesion Type & Qty
• • •
|
2# of Frz / Thaw Cycles
• • •
|
|
2DESTRUCTION MALIGNANT LESION
|
2DESTRUCTION CONSENT
|
|
2Destruction CRYO
|
2LIDO # of ML
|
|
2CRYO - Trunk, Arm, Legs
|
2SIZE of lesion : Trunk, Arms, Legs
• • •
|
|
2CRYO - Scalp, Neck, Hands, Feet
|
2SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
|
|
2CRYO - Face, Ears, Eyelids, Nose, Lip
|
2SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
|
|
2# of Frz / Thaw Cycles
• • •
|
|
|
2Cryo - BCC
|
2cryo - BCC - Loc
• • •
|
|
2Cryo - SCC
|
2cryo - SCC - Loc
• • •
|
|
2Cryo - SCCIS
|
2cryo - SCCIS - Loc
• • •
|
|
2CRYO- ADDL NOTES
|
|
|
2Destruction RF
|
2REQUIRED # of ML
|
|
2RF - Trunk, Arm, Legs
|
2SIZE of lesion : Trunk, Arms, Legs
• • •
|
|
2RF - Scalp, Neck, Hands, Feet
|
2SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
|
|
2RF - Face, Ears, Eyelids, Nose, Lip
|
2SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
|
|
2# of RF Applications
• • •
|
|
|
2RF - BCC
|
2BCC - location
• • •
|
|
2RF - SCC
|
2SCC - Location
• • •
|
|
2RF Notes
|
|
|
2DNA WOUND SWAB
|
2SWAB location
• • •
|
|
2Addl Notes
|
|
|
2Debridement
|
2Size: L mm x W mm x D mm
|
|
2Blade used
• • •
|
2Drainage Type&Amount
• • •
|
|
2Dressing type
• • •
|
2Addl Notes
|
|
2Dressing Change Performed
|
2Dressing change location
• • •
|
|
2Dressing type
• • •
|
2Addl Notes
|
|
2Dressing Change Regimen
|
2Regimens
• • •
|
|
2Dressing type
• • •
|
2Addl Notes
|
|
2OTC Tx Regimen
|
2OTC Topicals
• • •
|
|
2Addl Notes
|
|
|
2PRESCRIPTION
|
2Prescriptions
• • •
|
|
2Addl Notes
|
|
|
2.5FU INJECTION
|
2INJECTION SITE
• • •
|
|
2Treatment #
|
2Lot #:
|
|
2Expiration Date:
/
|
2Consent Obtained?
|
|
2LESION TYPE
• • •
|
2INJECTION SITE same as above
• • •
|
|
2QTY of MLs
|
2Administering Provider
|
|
2# MLs Lido mixed
|
2Was lido mixed?
|
|
2.5FU Addl Notes
|
|
|
2DermTech Adhesive Biopsy
|
2DermTech Addl Notes
|
|
2Intralesional Kenalog Injection
|
2Consent obtained?
|
|
2. # of lesions injected
|
2Kenalog Lesion Type
• • •
|
|
2INJECTION SITE
• • •
|
2Kenalog ML/volume
• • •
|
|
2Kenalog Type/ concentration
• • •
|
2Qty of lido mixed?
• • •
|
|
2Total volume inj w/ lido
• • •
|
2Lot #
|
|
2Expiration Date
/
|
2Administering Provider
|
|
2Kenalog Addl Notes
|
|
|
3Assessment
|
|
|
3Impression
• • •
|
3Location
• • •
|
|
3 Enter Counseling Macro here
|
|
|
3PIC3.1
|
3PIC3.2
|
|
3PIC3.3
|
3PIC3.4
|
|
3Treatment Deferred
|
3No Treatment Reason
• • •
|
|
3No tx notes
|
|
|
3PLAN: SHAVE REMOVAL
|
3SHAVE CONSENT
|
|
3# of ML Lidocaine
|
3SHAVE - Location
• • •
|
|
3SHAVE- Malignant
|
|
|
3Shave-Malig- Trunk,Extremity
|
3SIZE of lesion : Malig- Trunk,Extremity
• • •
|
|
3Shave-Malig- Hand,Foot,Neck.
|
3SIZE of lesion : Malig- Hand,Foot,Neck.
• • •
|
|
3Shave-Malig- Face, mm
|
3SIZE of lesion : Malig- Face, mm
• • •
|
|
3SHAVE - B9
|
|
|
3Shave- B9- Trunk-Extremity
|
3Shave- B9 -Trunk-Extremity
• • •
|
|
3Shave- B9- Hand,Foot,Neck.
|
3Shave- B9- Hand,Foot,Neck.
• • •
|
|
3Shave- B9- face- mm
|
3Shave- B9- face- mm
• • •
|
|
3Hemostasis + closing
• • •
|
3Addl notes
|
|
3CRYOSURGERY
|
3Cryo Consent
|
|
3Lesion Type & Qty
• • •
|
3# of Frz / Thaw Cycles
• • •
|
|
3DESTRUCTION MALIGNANT LESION
|
3DESTRUCTION CONSENT
|
|
3Destruction CRYO
|
3LIDO # of ML
|
|
3CRYO - Trunk, Arm, Legs
|
3SIZE of lesion : Trunk, Arms, Legs
• • •
|
|
3CRYO - Scalp, Neck, Hands, Feet
|
3SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
|
|
3CRYO - Face, Ears, Eyelids, Nose, Lip
|
3SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
|
|
3# of Frz / Thaw Cycles
• • •
|
|
|
3Cryo - BCC
|
3cryo - BCC - Loc
• • •
|
|
3Cryo - SCC
|
3cryo - SCC - Loc
• • •
|
|
3Cryo - SCCIS
|
3cryo - SCCIS - Loc
• • •
|
|
3CRYO- ADDL NOTES
|
|
|
3Destruction RF
|
3REQUIRED # of ML
|
|
3RF - Trunk, Arm, Legs
|
3SIZE of lesion : Trunk, Arms, Legs
• • •
|
|
3RF - Scalp, Neck, Hands, Feet
|
3SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
|
|
3RF - Face, Ears, Eyelids, Nose, Lip
|
3SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
|
|
3# of RF Applications
• • •
|
|
|
3RF - BCC
|
3BCC - location
• • •
|
|
3RF - SCC
|
3SCC - Location
• • •
|
|
3RF Notes
|
|
|
3DNA WOUND SWAB
|
3SWAB location
• • •
|
|
3Addl Notes
|
|
|
3 Debridement
|
3Size: L mm x W mm x D mm
|
|
3Blade used
• • •
|
3Drainage Type&Amount
• • •
|
|
3Dressing type
• • •
|
3Addl Notes
|
|
3Dressing Change Performed
|
3Dressing change location
• • •
|
|
3Dressing type
• • •
|
3Addl Notes
|
|
3Dressing Change Regimen
|
3Regimens
• • •
|
|
3Dressing type
• • •
|
3Addl Notes
|
|
3OTC Tx Regimen
|
3OTC Topicals
• • •
|
|
3Addl Notes
|
|
|
3PRESCRIPTION
|
3Prescriptions
• • •
|
|
3Addl Notes
|
|
|
3.5FU INJECTION
|
3INJECTION SITE
• • •
|
|
3Treatment #
|
3Lot #:
|
|
3Expiration Date:
/
|
3Consent Obtained?
|
|
3LESION TYPE
• • •
|
3INJECTION SITE same as above
• • •
|
|
3QTY of MLs
|
3Administering Provider
|
|
3# MLs Lido mixed
|
3Was lido mixed?
|
|
3.5FU Addl Notes
|
|
|
3DermTech Adhesive Biopsy
|
3DermTech Addl Notes
|
|
3Intralesional Kenalog Injection
|
3Consent obtained?
|
|
3. # of lesions injected
|
3Kenalog Lesion Type
• • •
|
|
3INJECTION SITE
• • •
|
3Kenalog ML/volume
• • •
|
|
3Kenalog Type/ concentration
• • •
|
3Qty of lido mixed?
• • •
|
|
3Total volume inj w/ lido
• • •
|
3Lot #
|
|
3Expiration Date
/
|
3Administering Provider
|
|
3Kenalog Addl Notes
|
|
|
4Assessment
|
|
|
4Impression
• • •
|
4Location
• • •
|
|
4 Enter Counseling Macro here
|
|
|
4PIC4.1
|
4PIC4.2
|
|
4PIC4.3
|
4PIC4.4
|
|
4Treatment Deferred
|
4No Treatment Reason
• • •
|
|
4No tx notes
|
|
|
4PLAN: SHAVE REMOVAL
|
4SHAVE CONSENT
|
|
4# of ML Lidocaine
|
4SHAVE - Location
• • •
|
|
4SHAVE- Malignant
|
|
|
4Shave-Malig- Trunk,Extremity
|
4SIZE of lesion : Malig- Trunk,Extremity
• • •
|
|
4Shave-Malig- Hand,Foot,Neck.
|
4SIZE of lesion : Malig- Hand,Foot,Neck.
• • •
|
|
4Shave-Malig- Face, mm
|
4SIZE of lesion : Malig- Face, mm
• • •
|
|
4SHAVE - B9
|
|
|
4Shave- B9- Trunk-Extremity
|
4Shave- B9 -Trunk-Extremity
• • •
|
|
4Shave- B9- Hand,Foot,Neck.
|
4Shave- B9- Hand,Foot,Neck.
• • •
|
|
4Shave- B9- face- mm
|
4Shave- B9- face- mm
• • •
|
|
4Hemostasis + closing
• • •
|
4Addl notes
|
|
4CRYOSURGERY
|
4Cryo Consent
|
|
4Lesion Type & Qty
• • •
|
4# of Frz / Thaw Cycles
• • •
|
|
4DESTRUCTION MALIGNANT LESION
|
4DESTRUCTION CONSENT
|
|
4Destruction CRYO
|
4LIDO # of ML
|
|
4CRYO - Trunk, Arm, Legs
|
4SIZE of lesion : Trunk, Arms, Legs
• • •
|
|
4CRYO - Scalp, Neck, Hands, Feet
|
4SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
|
|
4CRYO - Face, Ears, Eyelids, Nose, Lip
|
4SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
|
|
4# of Frz / Thaw Cycles
• • •
|
|
|
4Cryo - BCC
|
4cryo - BCC - Loc
• • •
|
|
4Cryo - SCC
|
4cryo - SCC - Loc
• • •
|
|
4Cryo - SCCIS
|
4cryo - SCCIS - Loc
• • •
|
|
4CRYO- ADDL NOTES
|
|
|
4Destruction RF
|
4REQUIRED # of ML
|
|
4RF - Trunk, Arm, Legs
|
4SIZE of lesion : Trunk, Arms, Legs
• • •
|
|
4RF - Scalp, Neck, Hands, Feet
|
4SIZE of lesion : Scalp, Neck, Hands, Feet
• • •
|
|
4RF - Face, Ears, Eyelids, Nose, Lip
|
4SIZE of lesion : Face, Ears, Eyelids, Nose, Lip
• • •
|
|
4# of RF Applications
• • •
|
|
|
4RF - BCC
|
4BCC - location
• • •
|
|
4RF - SCC
|
4SCC - Location
• • •
|
|
4RF Notes
|
|
|
4DNA WOUND SWAB
|
4SWAB location
• • •
|
|
4Addl Notes
|
|
|
4 Debridement
|
4Size: L mm x W mm x D mm
|
|
4Blade used
• • •
|
4Drainage Type&Amount
• • •
|
|
4Dressing type
• • •
|
4Addl Notes
|
|
4Dressing Change Performed
|
4Dressing change location
• • •
|
|
4Dressing type
• • •
|
4Addl Notes
|
|
4Dressing Change Regimen
|
4Regimens
• • •
|
|
4Dressing type
• • •
|
4Addl Notes
|
|
4OTC Tx Regimen
|
4OTC Topicals
• • •
|
|
4Addl Notes
|
|
|
4PRESCRIPTION
|
4Prescriptions
• • •
|
|
4Addl Notes
|
|
|
4.5FU INJECTION
|
4INJECTION SITE
• • •
|
|
4Treatment #
|
4Lot #:
|
|
4Expiration Date:
/
|
4Consent Obtained?
|
|
4LESION TYPE
• • •
|
4INJECTION SITE same as above
• • •
|
|
4QTY of MLs
|
4Administering Provider
|
|
4# MLs Lido mixed
|
4Was lido mixed?
|
|
4.5FU Addl Notes
|
|
|
4DermTech Adhesive Biopsy
|
4DermTech Addl Notes
|
|
4Intralesional Kenalog Injection
|
4Consent obtained?
|
|
4. # of lesions injected
|
4Kenalog Lesion Type
• • •
|
|
4INJECTION SITE
• • •
|
4Kenalog ML/volume
• • •
|
|
4Kenalog Type/ concentration
• • •
|
4Qty of lido mixed?
• • •
|
|
4Total volume inj w/ lido
• • •
|
4Lot #
|
|
4Expiration Date
/
|
4Administering Provider
|
|
4Kenalog Addl Notes
|
|
|
Addl Instruction
|
|
|
Education
|
Education Comments
|
|
Education
|
Education Comments
|
|
Education
|
Education Comments
|
|
Education
|
Education Comments
|
|
General Instructions
• • •
|
General Instruction Comments
|
|
FOLLOW UP
|
Follow Up
• • •
|
|
Reason for follow up
• • •
|
Patient to contact office with status update?
|
|
Addl Notes
|
|
|
Total Visit Time
• • •
|
Chart review/medication reconcilliation
|
