Appendix A. Skin and Soft Tissue Infection Action Plan

Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA)

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: __________________________

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Page last reviewed October 2014
Internet Citation: Appendix A. Skin and Soft Tissue Infection Action Plan: Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA). October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/mrsa/nc_mrsaapa.html