I need help charting skin issues!!

[Dixiecup]

This was always my weakness. Is there a good website or book that can help with describing skin issues. I see quite a bit and my charting sucks. It's embarrassing when I read it back. I don't mean what is a 'papule' or a 'macule' but describing things I see. i am just no good at it. Like rashes, etc. Also I did a pap on an older lady today and she had those raw, kind of hormonal patches on her labia and that's exactly what I charted but it sounded stupid. I need help!!!!

[BCgradnurse, MSN, RN, NP]

Not sure if this helps, but our EMR system charts skin stuff by first organizing it into rash vs. visible lesion, vs. palpable lesion. Then we have to describe it (macule vs. papule vs. nevus, etc.). Then distribution (isolated, scattered, dermatomal, etc), then location, size, number of lesions, other characteristics (painful, pruritic, scaly, etc.) then status (worse, spreading, improved, etc). Not a perfect system, but it covers the basics.

[sandnnw, BSN, MSN, EMT-B, APRN]

Check out Dains advanced assessments, Barbara Bates of course or Fitzpatrick is the bible for many Derm issues. I often use all three during the week in my clinic. BC is correct, a good template is also worth designing! Good luck.