Skin lesion history

Created 2017.

A structured referral letter or proforma may be useful in ensuring the required information is captured consistently. 

The following patient demographic data should be collated as standard:

• NHI
• Date of birth
• Gender
• Ethnicity

The proforma should also at least note the patient’s consent:

• Repeat and recent medications
• Other medical conditions.
• Allergies

Additional minimum information for a teledermatology referral for skin lesions:

• Date of onset/duration
• Whether single or multiple
• Location/s on body
• Size of the lesion
• Changes in size, shape, colour
• Any bleeding and/or ulceration
• Symptoms
• Any personal and/or family history of skin cancers
• Other risk factors, ie excessive sun exposure, fair skin, large number of naevi, immunosuppression, outdoor occupation etc.

A body map is also recommended to show the site of the lesion/s. At its most basic, this can be an image of a hand-written diagram or anatomic stamp