Acne Management Note

Date: [Encounter date]

Patient: [Patient identifiers per local policy]

Provider: [Provider name, credentials]

Visit Type: [new / follow-up]; [in-person / telehealth]

Subjective

Chief concern: "[Patient's own words summarizing goals or distress]"

[History of Present Illness narrative] (Cover onset and duration; distribution by region; patient-reported lesion types; perceived severity and psychosocial impact; scarring history or concern; relevant triggers; prior treatments with duration, adherence, response, and tolerability. Explicitly document any prior antibiotic exposure and total duration when present.)

Current skincare routine: [Cleansers, leave-on products, sunscreen, cosmetics, frequency]

[Pertinent medical history, current medications, allergies, and family history of scarring] (Include only if directly relevant to today's decisions.)

[Reproductive and hormonal history] (Include menstrual pattern, perimenstrual flares, signs of androgen excess, and pregnancy potential with current contraception when acne suggests hormonal contribution or when considering hormonal therapy or isotretinoin. Omit otherwise.)

Pregnancy status: [Not pregnant / Pregnant / Unknown] (Required when considering teratogenic or antiandrogen therapy. Must be explicitly documented, not inferred.)

Required information before proceeding: [Missing decision-critical items such as pregnancy status, prior antibiotic duration, baseline labs, or REMS steps] (Include only if applicable.)

Objective

• Skin exam: [Distribution by region and observed lesion types with counts or qualitative burden]
• Severity: [Grade and scale used: mild / moderate / severe with anchors, or IGA score]
• Scarring and dyspigmentation: [Atrophic / hypertrophic scarring; post-inflammatory hyperpigmentation and/or erythema]
• Exam limitations: [None / Limited due to telehealth, lighting, makeup, or occlusion] (Include if applicable.)
• Relevant tests: [Pregnancy test result with date; pertinent labs] (Include only when applicable.)

Assessment

Acne vulgaris

[Synthesis summarizing morphology, severity grade, distribution, and key modifiers such as hormonal pattern, scarring risk, antibiotic exposure history, or psychosocial burden]

Acne scarring

[Type and severity if active management is planned] (Include only if addressed today.)

Post-inflammatory hyperpigmentation/erythema

[Extent and patient concern if separate management is planned] (Include only if addressed today.)

Plan

Acne vulgaris

• Topical regimen: [Medication(s) with formulation, strength, application site, frequency, and titration] (For retinoids: include irritation mitigation—start every other night, pea-sized amount to dry skin, moisturizer layering, contingency if irritation occurs.)
• Oral antibiotic: [Agent, dose, frequency, indication, planned duration, reassessment plan, concurrent benzoyl peroxide to reduce resistance] (Include only if prescribed.)
• Hormonal therapy: [Agent, dose, rationale, pregnancy potential and contraception, monitoring] (Include only if prescribed.)
• Isotretinoin: [Indication criteria met; REMS enrollment status; baseline and follow-up testing plan; documented pregnancy prevention plan and test results; monthly monitoring cadence; dosing strategy and cumulative dose goal] (All elements require explicit documentation. Include only if initiating or continuing.)
• Adjunctive measures: [Skincare guidance, procedural options, lifestyle modifications] (Include only if relevant.)
• Counseling: [Time to improvement, adherence, application technique, photosensitivity, pregnancy precautions as relevant]
• Shared decision-making: [Patient preferences and rationale for chosen plan]

Acne scarring

[Management approach and treatment options discussed] (Include only if addressed today.)

Post-inflammatory hyperpigmentation/erythema

[Topicals, photoprotection, procedural options as applicable] (Include only if addressed today.)

Follow-up: [Timeframe matched to regimen: 8–12 weeks for topical initiation; 4–8 weeks for oral antibiotic reassessment; monthly for isotretinoin]

Contingency: [Instructions for severe irritation, allergic reaction, mood changes, or pregnancy concerns; clinic contact information]