M10.04.06 Documentation of Skin Findings

Accurate documentation of skin findings is essential in clinical practice. It ensures effective communication among healthcare providers, aids in the formulation of diagnoses, and contributes to the planning of treatment. This section covers the principles and methods for documenting skin findings, with an emphasis on clarity, accuracy, and completeness.

Importance of Documentation

• Communication: Ensures clear communication between healthcare providers.
• Legal Record: Provides a legal record of patient care and findings.
• Continuity of Care: Facilitates continuity of care and follow-up.
• Quality Control: Aids in the assessment of treatment efficacy and patient outcomes.

Principles of Effective Documentation

1. Accuracy: Ensure all details are correct and precise.
2. Clarity: Use clear and unambiguous language.
3. Completeness: Include all relevant information.
4. Consistency: Use standardized terminology and formats.
5. Timeliness: Document findings promptly after the examination.

Components of Skin Findings Documentation

• Location: Specify the exact location on the body (e.g., left forearm, upper back).
• Type of Lesion: Describe the type of lesion (e.g., macule, papule, nodule, vesicle).
• Size and Shape: Measure the size and describe the shape (e.g., round, oval, irregular).
• Color: Note the color (e.g., erythematous, hyperpigmented, hypopigmented).
• Texture: Describe the texture (e.g., smooth, rough, scaly).
• Distribution: Document the distribution pattern (e.g., localized, generalized, symmetrical, asymmetrical).
• Arrangement: Describe the arrangement (e.g., linear, clustered, annular).
• Other Characteristics: Note any additional features (e.g., crusting, ulceration, exudate).

Table: Common Skin Lesions and Their Descriptions

Key Points to Remember

• Be Specific: Always be as specific as possible about the location, size, and characteristics of lesions.
• Use Standard Terminology: Employ standardized medical terminology to describe findings.
• Photographic Documentation: When possible, supplement written documentation with photographs.
• Update Regularly: Regularly update the documentation to reflect any changes or progression.

Related Abnormal Conditions

• Basal Cell Carcinoma: Pearly, translucent nodule, often with central ulceration.
• Squamous Cell Carcinoma: Firm, red nodule or a flat lesion with a scaly, crusted surface.
• Melanoma: Irregular, multi-colored lesion, often with notched borders.
• Psoriasis: Red patches with silvery scales, commonly on the elbows and knees.
• Eczema (Atopic Dermatitis): Red, itchy, and inflamed skin, often with a history of allergies.
• Tinea (Ringworm): Ring-shaped, scaly, itchy patches.
• Herpes Zoster (Shingles): Painful, blistering rash following a dermatomal distribution.

Sample Patient Note

Patient Information

• Name: Jane Smith
• Age: 32
• Gender: Female
• Date of Examination: May 30, 2024
• Examiner: Dr. John Doe

Chief Complaint

• Patient reports a new rash on her right leg, noticed about two weeks ago.

History of Present Illness

• The rash started as a small, red patch and has since expanded.
• It is pruritic and slightly painful.
• No history of trauma to the area.
• No systemic symptoms such as fever or weight loss.
• No similar previous episodes.

Past Medical History

• Allergic rhinitis (diagnosed 10 years ago)
• No history of skin diseases

Family History

• No known family history of skin cancer or chronic skin conditions.

Social History

• Non-smoker
• No alcohol consumption
• Works as a teacher
• No recent travel or exposure to known allergens

Review of Systems

• No additional complaints reported

Physical Examination

General Appearance

• Well-nourished, well-hydrated female in no apparent distress.

Vital Signs

• Temperature: 98.7°F
• Pulse: 76 bpm
• Respiration Rate: 14 breaths/min
• Blood Pressure: 120/78 mmHg

Skin

• Location: Right anterior lower leg
• Type of Lesion: Plaque
• Size and Shape: Approximately 5 cm in diameter, oval-shaped
• Color: Erythematous with silvery scales
• Texture: Rough and scaly to palpation
• Distribution: Localized
• Arrangement: Solitary lesion
• Other Characteristics: No ulceration or crusting noted

Other Findings

• No regional lymphadenopathy
• No other significant skin findings

Assessment

• Primary diagnosis: Likely psoriasis
• Differential diagnosis: Eczema, tinea corporis, contact dermatitis

Plan

1. Topical Treatment: Prescribe a topical corticosteroid (e.g., hydrocortisone 2.5%) for application twice daily.
2. Patient Education: Advice on the importance of moisturizing the skin and avoiding known irritants.
3. Follow-Up: Schedule a follow-up appointment in 2 weeks to assess response to treatment.
4. Referral: Consider referral to dermatology if no improvement or if diagnosis is uncertain.

Key Points to Remember

• Document all relevant aspects of the skin lesion, including location, type, size, shape, color, texture, distribution, arrangement, and any other characteristics.
• Use clear and specific medical terminology to describe findings.
• Ensure thorough documentation of patient history, including medical, family, and social history, as well as a review of systems.
• Regularly update and review patient notes to monitor changes and ensure continuity of care.

Bibliography

1. Bolognia, J. L., Schaffer, J. V., & Cerroni, L. (2018). Dermatology. Elsevier.
2. Habif, T. P. (2017). Clinical Dermatology: A Color Guide to Diagnosis and Therapy. Elsevier.
3. Fitzpatrick, T. B., Johnson, R. A., & Wolff, K. (2019). Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. McGraw Hill Professional.
4. Marks, J. G., & Miller, J. (2017). Lookingbill and Marks’ Principles of Dermatology. Elsevier.
5. James, W. D., Berger, T. G., & Elston, D. M. (2015). Andrews’ Diseases of the Skin: Clinical Dermatology. Elsevier.

Conclusion

Proper documentation of skin findings is crucial in clinical practice. By adhering to standardized methods and principles, healthcare providers can ensure accurate, clear, and comprehensive records that enhance patient care and facilitate effective communication.