Comprehensive Documentation of Eczema in Patient Charts
When documenting eczema in a patient's chart, you should include detailed descriptions of the lesions, distribution pattern, severity assessment using validated scales, and impact on the patient's quality of life to ensure proper diagnosis, treatment planning, and monitoring of disease progression.
Key Elements for Eczema Documentation
1. Diagnostic Criteria
Document the presence of:
- Itchy skin condition (or report of scratching in children)
- Plus at least three of the following 1:
- History of itchiness in skin creases (folds of elbows, neck, or cheeks in children under 4)
- History of asthma/hay fever (or atopic disease in first-degree relatives for children under 4)
- General dry skin in the past year
- Visible flexural eczema (or eczema on cheeks/forehead/outer limbs in children under 4)
- Onset in first two years of life (for children under 4)
2. Lesion Characteristics
Record the following:
- Morphological features:
- Evidence of infection:
- Color variations based on skin type:
- Light skin: shades of red
- Medium to dark skin: purple to brown hues 3
3. Distribution and Extent
- Record the extent and location on a body map 1
- Document percentage of body surface area (BSA) involved 1
- Note characteristic distribution patterns:
4. Severity Assessment
Use at least one validated assessment tool:
- EASI (Eczema Area and Severity Index): measures extent and severity objectively 1, 5, 6
- SCORAD (SCORing Atopic Dermatitis): combines objective physician assessment with subjective patient symptoms 1, 5
- POEM (Patient-Oriented Eczema Measure): captures severity from patient perspective 1, 5
- IGA (Investigator's Global Assessment): simple scale for overall severity 5
5. Patient History Elements
Document:
- Aggravating factors and triggers 1, 7
- Sleep disturbance 1
- Coexisting atopic diseases 1
- Family history of atopic disease 1
- Previous treatments and responses 1, 7
- Use of steroids (topical or systemic) 1
- Dietary manipulations attempted 1
- Impact on quality of life (school, work, social activities) 1
- Patient's expectations from treatment 1
6. Treatment Plan and Follow-up
Document:
- Current treatment regimen:
- Plan for follow-up assessment (typically after 2 weeks of treatment) 7
- Education provided regarding chronic nature and proper application techniques 7
Sample Documentation Template
ECZEMA ASSESSMENT
HISTORY:
- Duration of symptoms: [duration]
- Pattern: [acute/chronic/recurrent]
- Aggravating factors: [list]
- Sleep disturbance: [yes/no, severity]
- Previous treatments: [list with responses]
- Atopic history: [personal and family]
- Impact on QOL: [description]
EXAMINATION:
- Distribution: [areas affected, % BSA]
- Morphology: [acute/chronic features]
- Signs of infection: [present/absent, type]
- Severity assessment:
* EASI score: [score]
* SCORAD: [score] (if used)
* POEM: [score] (if used)
ASSESSMENT:
- Diagnosis: [type of eczema]
- Severity: [mild/moderate/severe]
- Complications: [if any]
PLAN:
- Skin care: [emollients, bathing recommendations]
- Anti-inflammatory: [topical steroids - potency, location, frequency]
- Additional treatments: [if applicable]
- Trigger avoidance: [specific recommendations]
- Follow-up: [timeframe]
- Patient education: [topics covered]Common Documentation Pitfalls to Avoid
- Failing to distinguish between different types of eczema (atopic, nummular, contact)
- Inadequate description of distribution and extent
- Not documenting signs of secondary infection
- Omitting severity assessment using validated tools
- Incomplete documentation of previous treatments and responses
- Not addressing impact on quality of life
- Failing to account for skin tone variations when describing erythema in diverse skin types
By following this comprehensive documentation approach, you will create medical records that accurately capture the patient's eczema status, guide appropriate treatment, and allow for meaningful assessment of disease progression over time.