Documenting Past Medical History of Eczema in a SOAP Note
When documenting a PMH of eczema in a SOAP note, include the specific diagnostic features, disease severity and distribution, associated atopic conditions, previous treatments and their effectiveness, and impact on quality of life.
Essential Historical Elements to Document
Disease Characteristics
- Age of onset: Note if onset occurred in the first two years of life, as this is a key diagnostic criterion 1
- Distribution pattern: Document history of itchiness in skin creases (elbow folds, neck) or in children under 4 years, involvement of cheeks or forehead 1
- Current activity status: Specify whether the eczema is currently active, in remission, or has resolved 1
Associated Atopic History
- Personal atopic history: Document presence of asthma or hay fever 1
- Family history: Note any first-degree relatives with atopic disease, particularly important for children under 4 years 1
- General dry skin: Record if patient has experienced general dry skin in the past year 1
Disease Severity and Impact
- Extent and location: Document which body areas have been affected (flexural areas, face, hands, trunk) 1
- Severity markers: Note history of sleep disturbance, effect on school work, career, or social life 1
- Quality of life impact: Even mild eczema can be associated with severe morbidity, so document functional impairment 1
Treatment History to Include
Previous Therapies
- Topical corticosteroids: Document which potencies were used and their effectiveness 1
- Emollients: Note types used and frequency of application 1
- Other topical agents: Include tar preparations, calcineurin inhibitors (pimecrolimus, tacrolimus), or other treatments 1, 2
- Systemic therapies: Document any use of oral corticosteroids, cyclosporin, or other systemic agents 1, 3
- Phototherapy: Note if ultraviolet light therapy (UVB or PUVA) was used 1
Response to Treatment
- Effectiveness: Document which treatments provided control and which failed 1
- Adherence issues: Note any concerns about steroid use or other barriers to treatment 1
Complications and Triggers to Document
Infectious Complications
- Bacterial superinfection: History of crusting, weeping, or need for antibiotics 1
- Viral infections: Any episodes of eczema herpeticum (grouped punched-out erosions), viral skin infections, or warts 1, 2
Aggravating Factors
- Irritant exposure: Document known triggers such as soaps, detergents, wool clothing, or temperature extremes 1
- Dietary factors: Note any dietary manipulations attempted and their adequacy 1
- Contact allergens: History of contact dermatitis development 1
Common Documentation Pitfalls to Avoid
- Avoid vague terminology: Don't simply write "history of eczema"—specify the diagnostic features that confirm atopic dermatitis versus other eczematous conditions 1
- Don't omit immunization history in children: Vaccinations may have been omitted without good reason in children with atopic eczema 1
- Document current skin care practices: Include use of soap substitutes, bathing regimens, and moisturizer application frequency 1
- Note patient/family expectations: Document what has been most distressing for the patient or family, as this guides management priorities 1
Sample Documentation Framework
A comprehensive PMH entry might read: "Atopic dermatitis diagnosed at age 2 years with flexural involvement (antecubital and popliteal fossae). Personal history of asthma. Family history of hay fever in mother. Previously controlled with moderate-potency topical corticosteroids and daily emollients. History of one episode of bacterial superinfection requiring oral antibiotics. Known triggers include wool clothing and harsh soaps. Currently in remission. No sleep disturbance or functional impairment at present." 1
This structured approach ensures all clinically relevant information is captured for ongoing management and allows assessment of disease burden over time 1, 4.