Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Note:
Reason for Encounter
Briefly state the reason for this encounter. This could be:
Initial evaluation for acne vulgaris.
Follow-up visit for a patient with acne vulgaris.
Evaluation of treatment response for acne vulgaris.
Discussion of new or worsening acne.
History of Present Illness (HPI)
Onset and Duration: When did the acne begin? Has it been constant or intermittent?
Location and Severity: Where is the acne located (face, back, chest)? Describe the severity (mild, moderate, severe).
Lesion Type: What type of acne lesions are present (comedones, papules, pustules, nodules, cysts)?
Aggravating and Alleviating Factors: What makes the acne worse (certain foods, stress, cosmetics)? Does anything improve the acne (specific cleansers, medications)?
Past Treatments: Mention any previous treatments used for acne and their effectiveness.
Past Medical History (PMHx):
Briefly mention any relevant past medical history, such as:
Polycystic ovary syndrome (PCOS) in females
Prior use of medications that can worsen acne (corticosteroids, anabolic steroids)
Social History (SHx):
Include relevant social history that may be pertinent, such as:
Dietary habits
Skincare routine
Occupational exposures (oils, greases)
Medications
List all current medications the patient is taking, including over-the-counter acne treatments.
Allergies
Document any known allergies, especially to medications used for acne treatment.
Family History
Inquire about a family history of acne in first-degree relatives.
Physical Examination
Skin: Focus on the acne-affected areas, noting the location, type, and severity of lesions.
Scalp: Briefly assess for signs of scalp folliculitis (inflamed hair follicles).
Assessment
Summarize the key findings from the history and physical examination.
Classify the acne vulgaris based on severity (mild, moderate, severe) using a standardized scale (e.g., Investigator Global Assessment score).
Consider potential contributing factors like underlying hormonal imbalances or medications.
Plan
Outline the next steps in the patient’s management. This may include:
Patient Education: Educate the patient about acne vulgaris, the importance of a consistent skincare routine, dietary modifications if needed, and realistic expectations for treatment.
Topical Treatments: (First-line therapy for most cases)
Recommend a gentle cleanser and non-comedogenic (won’t clog pores) moisturizers.
Depending on the severity, topical retinoids, benzoyl peroxide, salicylic acid, or combination medications may be prescribed.
Oral Medications: (For moderate to severe acne or in combination with topicals)
Antibiotics (reduce inflammation)
Hormonal therapy (birth control pills for females with underlying hormonal factors)
Isotretinoin (powerful retinoid for severe acne, requires strict monitoring)
Comedone Extraction: (May be performed during the visit for some comedones)
Referral to a Dermatologist: For complex cases, severe acne, or patients with scarring concerns.
Prognosis
Briefly discuss the prognosis, which is generally good with consistent treatment. However, acne is a chronic condition that may require ongoing management.
Follow-up
Schedule a follow-up appointment to monitor response to treatment and adjust the plan as needed.
Additional Considerations
Adapt this template based on the specific situation (initial evaluation, follow-up visit).
Use clear and concise language while maintaining medical accuracy.
Document the specific acne treatment regimen prescribed or recommended.
Discuss potential side effects of medications and the importance of treatment adherence.
This template provides a framework for documenting progress notes for patients with acne vulgaris. Remember to tailor it to your specific workflow and facility’s documentation standards.