Recommended Format for Writing a Diagnosis of Systemic Lupus Erythematosus (SLE) on a Patient's Chart

When documenting a diagnosis of SLE on a patient's chart, include the disease name, specific organ involvement, disease activity status, and relevant laboratory findings to ensure proper monitoring and treatment. 1

Essential Components of SLE Documentation

Primary Diagnosis

Document "Systemic Lupus Erythematosus (SLE)" as the primary diagnosis 1
Include date of initial diagnosis if available 1

Specific Organ Involvement

Document all affected organ systems with specific manifestations:
- Mucocutaneous: Specify as LE-specific, LE non-specific, LE mimickers, or drug-related 1
- Musculoskeletal: Document type and location of arthritis 1
- Renal: Include nephritis classification if biopsy performed 1
- Neuropsychiatric: Specify manifestations (seizures, cognitive impairment, etc.) 1
- Hematologic: Document specific cytopenias 1, 2
- Other organ involvement: Cardiopulmonary, gastrointestinal, etc. 1

Disease Activity Status

Clearly state current disease activity: active, inactive, or in remission 1
Document any recent flares with dates 1
Include validated disease activity measures when available 1

Laboratory Findings

Include relevant autoantibody profile:
- ANA (titer and pattern)
- Anti-dsDNA
- Anti-Ro/SSA, Anti-La/SSB
- Anti-Sm, Anti-RNP
- Antiphospholipid antibodies 1
Document complement levels (C3, C4) 1
Include other relevant laboratory abnormalities (CBC, renal function, urinalysis) 1

Current Treatment

List all current medications with dosages 1
Document hydroxychloroquine status (as it's standard of care) 2
Include immunosuppressive agents if used 1, 2

Sample Format

Diagnosis: Systemic Lupus Erythematosus (SLE)
- Date of diagnosis: [Date]
- Current status: [Active/Inactive/Remission]
- Organ involvement:
  * Mucocutaneous: [Specific lesions]
  * Renal: [Lupus nephritis class if known]
  * Musculoskeletal: [Arthritis details]
  * Neuropsychiatric: [Specific manifestations]
  * Other: [Additional organ involvement]
- Laboratory findings:
  * ANA: [Titer and pattern]
  * Anti-dsDNA: [Positive/Negative, value]
  * Complement: C3 [value], C4 [value]
  * Other relevant antibodies: [Results]
- Current treatment: [Medications with doses]

Important Considerations

Monitoring Parameters

Include parameters that require regular monitoring:
- For patients with nephritis: proteinuria, serum creatinine, urinalysis 1
- For patients on antimalarials: ophthalmologic status 1
- For all patients: CBC, ESR, CRP, albumin at 6-12 month intervals 1

Disease Damage

Document accumulated organ damage from disease or treatment 1
Include comorbidities related to SLE or its treatment 1

Common Pitfalls to Avoid

Avoid documenting only "SLE" without specifying organ involvement, as this may lead to inadequate monitoring 1
Don't omit current disease activity status, as this guides treatment decisions 1
Include all relevant autoantibodies, not just ANA, as they provide prognostic information 1, 3
Document both active manifestations and cumulative damage to differentiate between current activity and permanent changes 1

What is the recommended format for writing a diagnosis of Systemic Lupus Erythematosus (SLE) on a patient's chart?

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