Psoriasis Systemic Therapy Note

Date/Time: [Date and time of encounter]

Visit Type: [Initial systemic therapy evaluation / Systemic therapy follow-up / Therapy change / Flare evaluation]

Provider: [Provider name and credentials]

History

[Narrative history covering psoriasis course and current control, interval changes since last visit, current regimen and adherence, symptoms and patient impact including itch/sleep/functional/psychosocial effects, and suspected triggers if relevant] (4–6 sentences; use concise, clinically focused language.)

• Prior Treatments: [Summary of prior topicals, phototherapy, and systemic agents with response and reason for discontinuation] (Include only if relevant to current therapy decisions; for stable follow-ups, note as reviewed/unchanged.)
• Special Sites: [Involvement of scalp, nails, face, palms/soles, genitals, intertriginous areas] (Document as these justify systemic therapy even at lower BSA.)
• PsA Screen: [Joint symptoms, morning stiffness, dactylitis, enthesitis, inflammatory back pain; screening tool result if used; referral decision]
• Safety Review: [Recent infections, TB/hepatitis risk factors; for patients on therapy: adverse effects and infection events since last visit] (If information is unknown, state what is missing and plan to obtain it.)

Relevant Medical History

• Comorbidities impacting drug selection: [CHF, demyelinating disease, IBD, liver/kidney disease, malignancy history, severe depression, or other relevant conditions]
• Cardiometabolic risk factors: [Relevant factors if present]
• Current medications of concern: [Medications with immunosuppressive, hepatotoxic, or interaction concerns]
• Allergies: [Medication allergies with reaction type]
• Vaccination status: [Summary relevant to immunosuppression]

Objective

• Skin Exam: [Morphology, distribution, and extent using standardized dermatologic terms]
• BSA: [Percentage of body surface area involved]
• PGA/IGA: [Score on specified scale, e.g., 0–4] (Use same scale at every visit for longitudinal tracking.)
• Special Sites: [Findings for scalp, nails, palms/soles, genitals, face as applicable]
• MSK Exam: [Focused joint, enthesis, dactylitis findings] (Include only if symptoms or suspicion warrant.)
• Data Reviewed: [Relevant labs and screening results with dates and interpretation — include CBC, CMP/LFTs, TB test type and result, hepatitis B serologies (HBsAg/anti-HBs/anti-HBc), lipids, pregnancy test as applicable to visit type; note pending results and whether therapy initiation awaits them]

Assessment

1. Psoriasis — [phenotype]: [Severity assessment anchored to BSA/PGA and special-site impact; response to current regimen; key modifiers affecting therapy selection]

• PsA status: [Present / Suspected / Screened negative] — [Referral decision if applicable]
• Treat-to-target status: [Target met (BSA ≤1%) / Acceptable response (BSA ≤3% or ≥75% improvement) / Not met]

2. [Additional active problem]: [Assessment] (Include only if relevant to therapy, e.g., monitoring concern, comorbidity requiring coordination.)

Plan

Psoriasis:

• Therapy decision: [Shared decision-making summary; options discussed; rationale for selected approach]
• Selected therapy: [Agent name, class, dose/route/frequency, loading regimen if applicable, start date or conditional start pending results]
• Adjunct therapy: [Bridge topicals, special-site management] (If applicable.)
• Response assessment: [Target and planned reassessment timeframe, typically ~12 weeks for biologics]

Monitoring and Safety:

• Baseline screening status: [Completed items; outstanding items and plan] (State if therapy will start now or await results.)
• Ongoing monitoring: [Next labs due; TB rescreening if high-risk; therapy-specific monitoring]
• Patient instructions: [Infection precautions, when to hold therapy, perioperative guidance, vaccination timing, pregnancy precautions as applicable]

Care Coordination: [Referrals placed and reason; PCP coordination for cardiometabolic or other comorbidity management] (Include only if applicable.)

Follow-up: [Timing and purpose of next visit]

(Use BSA and PGA/IGA at every visit for longitudinal comparison. For follow-ups, stable history may be noted as reviewed/unchanged, but interval changes and safety events must be actively documented.)