Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA)
Appendix A. Skin and Soft Tissue Infection Action Plan
Date: ___________________
Allergies:
Notes:
Fever:
History of Fever: Y N
Temperature at Visit: ________ ° 1 C ___ 2 F ___
Vital Signs:
Pulse –
Blood Pressure –
Risk for MRSA:
| __ Recent hospitalization (within 1 month) | __ Other skin condition__________________ |
| __ Family Member with MRSA (in last 6 months) | __ Immunocompromized:________________ |
| __ Sport team: ____________________________ | __Diabetes |
| __ History of MRSA: __________________ | __Other risk factor:_____________________ |
| __Excema | __None of the above |
Number of Infected Lesions: ________
| Site 1 | Site 2 | Site 3 | Site 4 | |
|---|---|---|---|---|
| General description of infection | ||||
| Duration (days) | ||||
| Location (face, neck, trunk, arm, hand, buttock, leg, foot, elsewhere) | ||||
| Size (cm, greatest diameter) | ||||
| Red (erythema) | Y N | Y N | Y N | Y N |
| Swollen (edema) | Y N | Y N | Y N | Y N |
| Warm | Y N | Y N | Y N | Y N |
| Painful/Tender | Y N | Y N | Y N | Y N |
| Other Findings | ||||
| Is it an abscess? | ||||
| Fluctuant | Y N | Y N | Y N | Y N |
| Yellow or White Center | Y N | Y N | Y N | Y N |
| Central Point or “Head” | Y N | Y N | Y N | Y N |
| Draining pus (discharge, purulent) | Y N | Y N | Y N | Y N |
| Other Findings | ||||
| Was it Drained? | ||||
| I&D | Y N | Y N | Y N | Y N |
| Needle Aspiration | Y N | Y N | Y N | Y N |
| Manually Expressed | Y N | Y N | Y N | Y N |
| Packed | Y N | Y N | Y N | Y N |
| Referred for Further Management to: | ||||
| Was a Culture and Sensitivity Analysis Obtained? | ||||
| Y N | Y N | Y N | Y N | |
Summary of other sites if more than four:
Antibiotic:
___ None
___ Empiric Treatment for suspected MRSA
(e.g., clindamycin, doxycycline, minocycline, trimethoprin-sulfamethoxazole)Rx: ____________________________________
___ Empiric Treatment for non-MRSA or Streptococcus (e.g., beta lactam)
Rx: ____________________________________
___ Other Rx: ____________________________________
Patient Followup:
___ PRN
___ Scheduled for _______ days
Patient Education:
___ CDC Information Sheet
___ Other: __________________________
CPT Codes:
10060 – Simple or single I&D or needle aspiration
10061 – Complicated or multiple I&D or needle aspiration
ICD-9 Codes:
041.1 Staphylococcus infection
680.X* Carbuncle or furuncle
681.00 Cellulitis or abscess of finger
681.10 Cellulitis or abscess of the toe
681.9 Cellulitis or abscess of unspecified digit
682.X* Other cellulites or abscess
* X=.0 face, .1 neck, .2 trunk, .3 arm, .4 hand, .5 buttock, .6 leg, .7 foot, .8, head, .9 elsewhere
Follow-up:
___ Final Culture Result: ____________________________________ Date: _______________
___ Patient Notified: Y N ; Date: __________________
___ New Rx: __________________________
___ Other: __________________________
Page originally created September 2012
The information on this page is archived and provided for reference purposes only.
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