Atopic Dermatitis Management Note

Date: [Date]

Patient: [Patient name or identifier]

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

Subjective

Chief Concern: [Primary concern in one line] (Use patient's own words when available.)

HPI: [Narrative describing onset and course; current distribution; itch intensity (0–10); sleep disruption (nights/week); functional impact on daily activities; suspected triggers or exacerbating factors; measures that provide relief] (For follow-up visits, include disease trajectory [better / worse / unchanged] and reported treatment adherence.)

Treatment History: [Summary of prior and current therapies with response, including topical corticosteroids by potency class and body sites, nonsteroidal topicals, systemic therapies or phototherapy if applicable, and supportive measures; note barriers, adverse effects, and patient concerns] (If details cannot be obtained, document as "unknown" or "records unavailable".)

Objective

Exam: [Distribution by anatomic region; morphology noting acute features (erythema, edema, oozing/crust) and/or chronic features (lichenification, excoriations); signs of secondary infection if present; special-site involvement (face/eyelids, hands, flexures, genitals) as applicable; estimated body surface area involved]

Severity: [mild / moderate / severe] — Basis: [BSA, special-site involvement, symptom impact, validated instrument scores if collected]

Data: [Photos, labs, patch testing results, or external records reviewed with pertinent findings] (Omit entirely if no external data reviewed.)

Assessment

Primary diagnosis: Atopic Dermatitis — [mild / moderate / severe] (Basis: [BSA, special sites, symptom impact]). Current status: [flare / controlled / improving / worsening].

Associated problems: [Pruritus severity; sleep disruption; secondary infection; treatment adverse effects; quality-of-life impact as relevant] (List only those clinically significant; omit if none.)

Differential considerations: [Differential diagnoses] (Include only if diagnosis is uncertain; otherwise omit.)

Plan

Foundational Care: [Emollient/moisturizer plan with frequency; bathing guidance provided; trigger counseling delivered]

Topical Regimen: [Medication name, strength, vehicle — application sites, frequency, duration; maintenance or step-down plan; steroid-sparing approach for sensitive sites if applicable]

Itch and Sleep: [Nonpharmacologic measures recommended; pharmacologic interventions if used with dose and safety counseling]

Infection: [Supporting exam findings; culture plan if obtained; treatment initiated; return precautions] (Include only if secondary infection suspected; otherwise omit entirely.)

Escalation Plan: [Criteria met for inadequate control; next step under consideration (phototherapy referral or systemic therapy) with rationale; baseline screening and counseling if initiating advanced therapy] (If not escalating, note contingency criteria for future escalation.)

Follow-up: [Interval based on severity and therapy risk] — Success/failure criteria: [clinical targets such as symptom control, BSA reduction, sleep improvement]