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Keep your attention on the care encounter.
Record the conversation and clearly state your own findings and agreed actions.
Hysio Dermatology
Hysio organises what you say and see in a dermatology encounter: the reason for the visit, skin findings, results provided and the follow-up discussed. The assessment remains yours.
A structured report in your professional terminology
From care encounter to report
Hysio turns spoken information into a report. Choose the report format for the conversation you are documenting.
Document
Record the conversation and clearly state your own findings and agreed actions.
AI assistants
You stay in control of what gets saved.
In your workday
More attention for the conversation, less typing afterwards.
State relevant information, your own findings and agreed actions aloud so you can find them in your report.
The information appears under the headings of your chosen report format, so you can review each section.
Check names, facts and agreed actions. Edit the text where needed before using the report in your records.
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For your team
Quick answer
A profession-specific structure for skin, hair, nails and mucous membranes, with room for the reason for the visit, your own observation, results provided and the agreed follow-up.
Read how Hysio works in a dermatology consultation, an intake, a biopsy or a short follow-up contact.
That depends on the encounter and not on the complaint. A detailed first history belongs in the dermatology intake, an assessing clinic encounter in the dermatology consultation, a dictation of an examination or outpatient procedure in the examination and procedure report, and a short journal entry in the SOAP note. You describe location, borders and morphology in all four in the words of the source. Which format this encounter takes remains your choice. [2] [3] [4] [5] [1] [11]
Work with fixed sections that follow the encounter: reason for the visit and referral, medical history, focused history, physical examination, investigations provided, conclusion and management plan. What you see, meaning morphology, colour, borders, location and side, belongs with the examination. A pathology or laboratory report that was provided keeps its own date, source and conclusion separate, so that it does not merge with your conclusion. Hysio puts those parts in their place and leaves the order of the encounter intact. [2] [1] [10]
Hysio creates a report from what was said and recorded in the encounter. You read it back, correct what is not right and transfer the text into your medical record system yourself; there is no automatic write action to a record. Complaints such as itching, pain and course stay in the words of the source, with the role of whoever mentioned them. That way the route from spoken encounter to record entry remains yours at every point. [10] [1] [2]
Only record what this encounter needs. The formats deliberately leave name, date of birth, citizen service number, record number and institution out of the text, even when they were mentioned in the source. Sensitive topics, for example anogenital complaints or a sexually transmitted infection, only appear when they were actually discussed. You record consent to share something separately and traceably. Processing is GDPR-compliant and the data is hosted in the European Union. [8] [14] [1]
Hysio works with three monthly plans: Starter for €20, Pro for €40 and Unlimited for €80 per month, each excluding VAT. If you pay yearly, you get two months free. The price is not specific to dermatology: you pay per person and not per documentation format or per procedure. If you want to try it first, there is a free trial of fourteen days without a credit card. The current terms and the number of sessions per plan are on the pricing page. [6] [7]
Your own template or macro in your record system works well for short, highly repetitive encounters in which you type the same lines every time anyway, for example a short check-up after a previously treated skin lesion. Hysio is intended for encounters in which a lot is said and the origin matters: who reported something, what you saw and what you decided afterwards. You can keep both side by side. Compare them on one point: which text can a colleague still follow later without you there. [1] [10] [11]
Read the report next to what you actually said and saw. Pay particular attention to three things: is there a conclusion that you did not state, is a result provided presented as your judgement, and has a measurement or score been filled in that nobody mentioned. If something is missing, a fixed sentence should appear there stating that the section is not documented in the source provided. A fixed structure makes a report recognisable, not yet correct; that check remains your work. [1] [11] [9]
During a skin examination you look, and typing at the same time does not combine well with looking. That is why this way of documenting is designed around speech: you describe out loud what you see and discuss, and the text follows afterwards. That saves screen time while you inspect skin, hair, nails and mucous membranes and while you examine a lesion with a dermatoscope. Tell the patient what is being recorded and why; that is part of the encounter and makes the later text more honest. [1] [2] [10]
The difference lies in the organisation and in the boundary. A general text assistant produces a smooth summary; the dermatology formats keep the roles apart, meaning what the patient reported, what a relative added, what the referrer wrote and what you saw. A pathology report that was provided keeps its own conclusion separate from yours. And nothing is filled in: no diameter, no score, no stage and no differential diagnosis that was not stated. [1] [2] [10]
An introduction that lasts starts small and recognisable. Choose one encounter type that comes up often, for example the outpatient follow-up encounter, and keep that up for a number of weeks. Agree who reviews the report and who puts the text in the record, so that this does not happen by chance. Collect the corrections you make; they show which sections work differently in your practice. Only once that runs smoothly do you add a second encounter type, such as the procedure dictation. [7] [8] [1]
This is the format for the outpatient encounter in which you assess, conclude and agree a management plan. The text runs from reason for the visit and referral via medical history and focused history to physical examination, investigations provided, conclusion and management plan, and opens with a plain summary. The outcome can be used to report back to the referrer. A conclusion from a report provided stays with that investigation and never becomes the main conclusion. You decide what goes into the record. [2] [1] [11]
The intake is the detailed first history: the reason for the visit, course, medical history, previous treatment and the context in which the complaint occurs. Patient, relative, referrer and investigations provided remain separate sources, even when they contradict each other; two different starting points for the same lesion then stay side by side. Sections such as social history, active diagnoses and expectations only appear when they were covered. The conclusion contains only what you, as the treating dermatologist, have stated. [3] [1] [11]
This is the direct dictation of a dermatological examination or an outpatient procedure. The text keeps apart the reason, the practitioners involved, the procedure itself, the findings, particulars or complications, material taken, investigations provided, conclusion and the aftercare stated on the spot. Information and preferences are only included when they were discussed. Taking and sending a biopsy are noted as actions; they say nothing about receipt, assessment or result. Technique, instrument or follow-up are not filled in. [4] [1] [11]
The SOAP note is the short journal entry for your own record, not the letter to the referrer. It organises what the patient reports under Subjective, what you see yourself under Objective, your appraisal under Assessment and the agreement under Plan. It fits a focused follow-up encounter, for example the moment a result from an earlier sample comes back and you decide whether monitoring is still needed. There is no dermatology guideline that prescribes this structure; it is a widely recognised practice format. [5] [1] [11]
Choose by destination and not by quantity. A clinic encounter in which you assess and agree a management plan belongs in the consultation format; if an excision or biopsy is done in the same appointment, that action gets its own procedure report with its own practitioners, findings and aftercare. That way you can later find who did what. If it is only a short journal entry about a result, the SOAP note is enough. Two separate texts are clearer than one text in which both run together. [1] [2] [11]
The intake describes the starting point: the reason for the visit, the course so far, medical history and what has been tried before. A follow-up encounter describes the change compared with that starting point and does not repeat the whole history. If you see someone again after years with a different skin complaint, a new intake is usually more honest than a follow-up entry, because the context really is different. If in doubt, consider what the reader will look for later: the beginning or the difference. [1] [2] [11]
Describe what actually happened: the reason, who performed the procedure and who assisted, the procedure itself, the findings on the skin, particulars such as limited bleeding, the material taken and the aftercare you stated on the spot. Only measurements, numbers and locations that were mentioned go into the text; a diameter, side or anatomical layer is not estimated. If a section is not documented, it says so, and not as a clean standard sentence. [1] [2] [11]
Feedback contains the reason, what you saw, your conclusion, the agreed management plan and what the recipient needs to do or monitor. Investigations provided are included with their own date, source and conclusion, so that the GP can see who established what. Leave out what the recipient does not need; a full account of the conversation is not a better letter. Check purpose and consent before you share data. The letter only becomes final when you send it yourself. [1] [2] [11]
Keep three layers apart: the account of the patient or a relative, your own observation of the skin, and the result that someone else established. In the text, each layer gets its own place with the role attached. If the patient says that a lesion changed in July and the partner says it was August, both reports stay with their source; they are not quietly merged into one date. Only your own appraisal makes something of that; that is how admin with AI stays verifiable. [1] [2] [11]
Describe the same features in the same order for each encounter: location and side, colour, borders, surface and the measurement you mentioned yourself. Then a difference is readable later without you having to find the lesion again. Only name change that you actually established; text from a previous encounter is not carried over to this encounter. If photographic documentation was made without you linking a finding to it, the text states that the image was made and nothing more. [1] [2] [11]
Record the reason for the visit in the words in which it was put, with course, triggering moments, previous treatment and its effect. Itching, pain, burning and the impact on sleep or work belong there when they were discussed. If someone says that they feel a lesion started to change in the summer, that wording stays; no date or year is invented. What was not covered stays empty instead of being filled with an assumption. [1] [11]
Every statement gets the role of the person who made it: patient, partner or relative, referrer, nurse, pathologist or laboratory. Those roles are not merged, not even when they say the same thing. That is not a formality: with a pigmented lesion it matters whether the change was noticed by the patient or seen by someone else. Incidentally, being present at the conversation does not prove representation or consent; you record that separately. [1] [14] [11]
A measurement or score only goes into the text when it was mentioned, with instrument or version, value, date and source. A severity score or questionnaire such as PASI, SCORAD, POEM or DLQI is not calculated, not completed and not converted, and a partly completed list does not become a total. You take over a diameter as you stated it; nothing is estimated from a description or a photograph. What the outcome means for this patient remains your judgement. [1] [11]
For a result, always note the investigation, the date, the source and which lesion it concerns. A histology report keeps its own conclusion with the investigation provided; your conclusion stands apart from it and is the only one that counts as your judgement. If material was taken but the result has not come back yet, the text says so too. Sending is not receipt and receipt is not assessment. That way it stays visible what is established and what is still pending. [1] [11] [14]
No. No photograph, no dermatoscopic image and no histological section is assessed, so no diagnosis, measurement or estimate of malignancy follows from an image either. What is recorded is that an image was made and what you said about it. A report provided by someone else may be taken over with source, date and its own conclusion. If photographic documentation was made without you linking a finding to it out loud, it remains an action performed without a result in the text. [10] [9] [11]
Hysio keeps to your words and does not translate professional language into something simpler. Descriptive terms for efflorescences, borders, colour and scaling stay as you say them. Agree within your specialty group which abbreviations you use and write them out in full the first time, because an abbreviation that is self-evident to you may mean something else to the GP or a locum. If you doubt whether a term is unambiguous, writing it out is the safest choice. [1] [11]
Note who the information comes from and when it was given. What a partner notices about a change in a lesion is valuable, but it is a different source from the patient and a different one from the referral letter. If they contradict each other, both accounts stay until you weigh them. If you want to share information with a relative, the usual rules on consent and professional confidentiality apply; you record that consent separately and not implicitly. [1] [14] [11]
A discussion needs only three things: what it is about, what has been established and with which source, and which question is on the table. In dermato-oncology that is often a histology result next to your own finding. Make visible which discipline provided which information and who takes up the follow-up, so that an agreement does not get stuck between diaries. What was decided in the meeting then goes back into the record with name and date. [1] [2] [14]
Take a pigmented lesion on the forearm that, according to the patient, has been changing since the summer. The intake records the reason for the visit, the course and the partner's differing report. The consultation adds your description of the lesion and your management plan. The procedure report describes the dermatoscopy and the biopsy, with practitioners, findings and aftercare. The SOAP note then records the short contact at which the result comes back. That is how voice-driven admin works around one lesion: nowhere does a diagnosis arise that was not stated. [1] [11] [2]
By keeping visible for each section where it comes from. What the patient reported stands as a report, what you saw as your own observation, and a result with investigation, date and the body that issued it. Do not copy a sentence from an earlier letter without checking whether it is still correct. Only write down what was discussed or provided in this encounter. Only send once you have reviewed the text yourself; until then it is not final. [10] [8] [14] [11]
No. Hysio records what you observed, discussed and decided, and itself makes no diagnosis, no differential diagnosis and no indication. If you do not state a conclusion, no conclusion goes into the text either; it then states that the source provided does not contain one. A pathology result that was provided remains the pathologist's conclusion and does not become your judgement. The distinction between a suspicious and a harmless lesion is made by the dermatologist, not by the report. [9] [1] [11]
You. Hysio creates a report and you decide which parts of it go into the record, in which wording and under which heading. The medical specialist providing the care remains responsible for the content of the record entry and for what goes to a colleague. If a physician assistant or nurse practitioner is involved, tasks, supervision and lead practitioner responsibility follow the legal frameworks and local agreements; a documentation format does not shift that division. [1] [9] [14]
Then the section stays empty with a fixed sentence stating that it is not documented in the source provided. No value, date or conclusion is estimated and no standard wording is filled in that suggests a normal course. Sections that only belong to certain encounters, such as material taken or preferences discussed, disappear from the text when they were not covered. If there is too little source for a whole report, a refusal follows instead of a filled-in text. [1] [9] [11]
Not to determine how urgent something is. Hysio does not triage and does not weigh urgency; in an acute situation you act first and document afterwards. An urgent assessment of, for example, a rapidly spreading skin lesion remains entirely your professional judgement and goes through your own arrangements. Afterwards, the structure does help to record course, assessment and decision, with the times you mentioned yourself. [9] [8] [11]
Sharing follows the usual rules on professional confidentiality and consent, not the possibilities of a text. For every message, check the purpose, the recipient and whether there is consent, and record that consent with date and scope. The presence of a relative at the conversation is not consent to share with that relative later. Limit what you send to what the recipient needs; with sensitive topics that is usually less than the whole report. [8] [14] [1]
No. A management plan only goes into the text when you stated it, and then in your wording. No medicine, strength, procedure or follow-up interval is chosen and no next step is filled in that seems logical but was not discussed. Sections on medication, allergy or side effects are not built up as a separate overview; a medication fact that was mentioned stays in the section where it came up. What you agree, you decide together with the patient in the consulting room. [9] [10] [11]
As you state it. If you say that a lesion looks suspicious but that histology has to confirm it, that reservation stays; it is not smoothed over into a firmer sentence. Open points, a result not yet received and an agreed follow-up check stay visible. That is not carelessness but information: a colleague who takes over the encounter can see what is not yet established and what you are waiting for. [1] [11] [9]
Leave them both, with their origin. If the referral letter says something different from the patient, or an earlier report differs from what you see now, that difference is not polished away and not quietly resolved. The difference is often precisely the clinically useful information. You weigh which account takes precedence and write that down as your conclusion, so that others can later trace which account you followed and why. [1] [14] [11]
Only verbatim from the source. A medicine that was discussed stays in the section where it came up, with the words that were used. A decision about medication only goes under the management plan once you have stated that decision. Measured values keep their unit, moment and source and are not converted or summarised into a trend. No separate overview of active or planned medication is created, because such a list suggests a completeness that one encounter is not able to deliver. [1] [11] [9]
Read the text through completely once before you save it, and not just the conclusion. Check whether the correct location and side are there, whether the management plan matches what you agreed, and whether no sentence from an earlier encounter has been left in. Correct in the text itself and not in your head. Then save it under your own name and according to the agreements of your specialty group; whoever saves it vouches for it. [1] [8] [9] [14]
For a locum or shift handover, what matters is different from a letter: what is still ongoing. Note which results are still outstanding, which follow-up check has been agreed and what you told the patient to expect. Keep it short and traceable; the colleague who takes over must see at a glance what is established and what is not. Agree where that handover ends up, so that it does not get stuck in a separate message and cannot be found later. [10] [8] [14] [2]
Make three things explicit in advance. First, which format belongs to which encounter, so that not everyone chooses something different. Second, which sections and terms you keep to, including abbreviations. Third, who reviews and saves a text when several people work on the same encounter, for example during a procedure with an assisting colleague. Without those agreements, variants arise that only become noticeable when someone has to read another person's record. [1] [2] [10]
Decide in advance what you will measure it against. Take one defined clinic, agree a period and collect two things per encounter: how much you had to change in the text and whether the text was readable for a colleague. Discuss those changes with each other instead of only correcting them yourself; that is where the information is. If a particular section keeps being filled in differently, an agreement is missing there and it is not a matter of one person. [7] [8] [1]
Check the text against the layout and order you use in the record and adjust it where needed before you save. Hospitals register diagnoses and procedures in their own thesauri; that coding belongs in the registration system and not in the report text. Authorisation, co-signing and who may record which part follow your own arrangements. If your department really works differently on a point, record that as an agreement instead of as an exception each time. [10] [1] [11]
After clinic you no longer have to type up the skin descriptions. You say the location, morphology and your management plan, and Hysio turns it into the report. That is voice-driven reporting. You measure how much it saves yourself, over a few clinic sessions. [1] [11] [2]
Measure it yourself and do not rely on a general percentage. Take a fixed period, count how many encounters you documented this way and keep track of how many you still had to change afterwards. Include the editing afterwards, because that is where the real difference lies and not in the speed of the first version. Also look at something no clock measures: whether you still have a pile of open entries at the end of your clinic. What you measure applies to your clinic. [1] [10] [7]
Hysio has a free trial of fourteen days without a credit card, and the plan can be cancelled monthly. During that period, assess two things in particular: does the organisation fit the way your department writes, and how much do you still have to change afterwards. Involve a colleague, because a text that reads logically to you must also be correct for a locum. The current terms are on the pricing page and on the legal page. [7] [6] [8]
The amounts and plan types are on the pricing page, the processing of data in the privacy policy, and the limits of use in the disclaimer and the legal information. Those pages are authoritative and take precedence over what is briefly stated here. What you read there is an agreement between your practice and Hysio; it is not a dermatology standard and does not replace a guideline or institutional policy. For professional requirements, your association and your department remain the source. [6] [8] [9]
Write down what you already do the same way every time: the order in which you describe the skin, the way you indicate location, and the fixed sentence with which you note a follow-up appointment. A short list of half an A4 page is enough. Share it with your colleagues and update it as soon as you notice that you have started phrasing something differently. Hysio follows your words, so the sharper your own writing style, the less you have to change afterwards. [1] [10] [11]
Split by problem and by source instead of putting everything in one long text. Someone with several skin problems at once gets their own line per problem: what is the question, what did you see, what is the result and what has been agreed. Put reports provided separately with their own date and conclusion. What is still open stays visible as an open point. That way a complicated course stays readable without a summary conclusion emerging that nobody stated. [1] [11] [2] [9]
Hysio creates the report. You remain responsible for what you save in the record.