What is the proper way to document oral thrush in a medical note?

Documentation of Oral Thrush in Medical Notes

The proper documentation of oral thrush in a medical note should include detailed description of white plaque-like lesions that can be wiped off revealing erythematous or bleeding surfaces, along with location, extent, and associated symptoms. 1, 2

Essential Elements to Document

Clinical Appearance

• Document the presence of creamy white, curd-like plaques on erythematous bases that can be wiped off, leaving erythematous or bleeding surfaces 2
• Note the specific locations affected (tongue, buccal mucosa, palate, etc.) 1, 2
• Record the extent of involvement using descriptive terms (e.g., localized, diffuse, patchy) 2

Associated Symptoms

• Document any reported symptoms such as burning sensation, altered taste, or pain 2
• Note any difficulty with eating or swallowing that may indicate esophageal involvement 1
• Record any associated dryness of the mouth 1

Physical Examination Findings

• Document the appearance using specific terminology: pseudomembranous (removable white plaques), erythematous (red patches), or hyperplastic (non-removable white plaques) 3
• Note if lesions are easily wiped away with a tongue depressor or gauze (characteristic of pseudomembranous candidiasis) 2
• Document any angular cheilitis (cracks at corners of mouth) which may be associated 4

Risk Factors and Contributing Conditions

• Document relevant medical history that may predispose to oral thrush (immunosuppression, diabetes, recent antibiotic use) 5
• Note use of inhaled corticosteroids, dentures, or other local factors 1
• Record recent treatments attempted for the condition 6

Sample Documentation Template

Oral Cavity Examination: 
- Appearance: [Describe white plaques - distribution, thickness, removability]
- Location: [Specific areas affected - buccal mucosa, tongue, palate, etc.]
- Extent: [Percentage or descriptive assessment of oral cavity involvement]
- Associated findings: [Angular cheilitis, xerostomia, etc.]
- Symptoms: [Pain, burning, altered taste, odynophagia]
- Removability test: [Results of attempting to wipe away plaques]
- Predisposing factors: [Relevant medical conditions, medications]
- Previous treatments: [Prior antifungal therapies and response]

Common Pitfalls in Documentation

• Failing to distinguish between pseudomembranous candidiasis (removable white plaques) and leukoplakia (non-removable white patches) 2
• Not documenting the removability of the white plaques, which is a key diagnostic feature 2
• Omitting assessment of other oral sites beyond the tongue 1
• Neglecting to document relevant risk factors that may guide management 5
• Failing to note previous treatments and their effectiveness 6

Clinical Pearls

• Always document whether the white plaques can be removed, as this distinguishes oral thrush from other white lesions 2
• Include photographs in the electronic medical record when possible for serial comparison 1
• For recurrent cases, document any potential underlying systemic conditions that may require further investigation 7
• When documenting oral thrush in immunocompromised patients, note the extent more carefully as it may indicate systemic involvement 1