Dermatology Care Plan Template
- Mohammad Al-Ubaydli
Owned by Mohammad Al-Ubaydli
Have a look through the template, the care plan can be adapted to suit your patient cohort.
Urticaria Activity Score (UAS7) Care Plan
Key objectives
To use PKB to facilitate remote communication and monitoring with patients.
Outcome measures
Equip every patient with a specific patient-reported measure. Patients to document 24-hour self-evaluation scores over 7 consecutive days to create the UAS7 within a shareable and editable digital care plan.
Current Baselines
All activity is face to face, patients are travelling large distances, and their follow-ups aren’t being efficiently, or effectively managed.
Workflow
Team: Adds care plan to the patient's record
Patient: Uses care plan to record daily symptoms for seven days
Team: Ability to view patients UAS7 score and review in appointments along with other data in the record
Urticaria Activity Score (UAS7) Care Plan Template
Example care plan template code for Urticaria Activity Score (UAS7) Care Plan HTML
<div class="form-inline">
<style media="screen">
.form-group {width: 100%; !important}
ul {list-style:inherit; margin-left: 15px;}
.cp_whiteBox {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px;}
</style>
<div class="cp_whiteBox">
<h2>Using the UAS7 in routine clinical practice to assess disease activity in patients with CIU*</h2>
<p style="font-size: 50%;"><sup>*</sup>UAS7: weekly Urticaria Activity Score; CIU: chronic idiopathic urticaria <br />
<sup>†</sup>Chronic idiopathic urticaria is sometimes referred to as chronic spontaneous urticaria.</p>
<h3>UAS7: A tool to assess disease activity in patients with CIU</h3>
<p>Chronic idiopathic urticaria (CIU) is a skin disorder characterized by the spontaneous appearance of wheals and/or angioedema for at least 6 weeks.<sup>1</sup></p>
<p>The <b>Urticaria Activity Score (UAS)</b> is a CIU-specifi c patient-reported measure. It is based on the assessment of key CIU symptoms: <b>number of wheals</b> and <b>intensity of itch</b>.<sup>1</sup></p>
<p>Patients with CIU are advised to document 24-hour self-evaluation scores. Daily UAS scores are summed over 7 consecutive days to create the UAS7, with higher scores indicating greater disease severity.<sup>1</sup></p>
<p class="cp_whiteBox" style="background-color: #E1DEDC;">The UAS7 should be used in routine clinical practice to determine disease severity in patients with CIU. Comparing UAS7 scores at different visits enables to monitor disease activity over time.<sup>1</sup></p>
<p class="cp_whiteBox" style="color: #E40178; border: 2px solid #E40178;">Please remind patients to bring their completed questionnaires to their next visit.</p>
<h2>Weekly Urticaria</h2>
<h3>Activity Score (UAS7)</h3>
<p>Complete this questionnaire over 7 consecutive days. Your responses will help your doctor assess how active your chronic idiopathic urticaria (CIU) is. Please circle the score that corresponds to the number of wheals you have and the score that represents the intensity of your pruritus (itching) on a daily basis (see description in chart below). Remember to bring your completed questionnaire to your next visit.</p>
</div>
<div class="cp_whiteBox">
<h2>Day 1</h2>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyWheals_1"><h3>Daily number of wheals</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyWheals_1" id="cp_dailyWheals_1">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyPruritus_1"><h3>Daily intensity of pruritus</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyPruritus_1" id="cp_dailyPruritus_1">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row" style="background-color: #C9C1BF;">
<div class="col-sm-6">
<label for="cp_dailyUASscore_1"><h3>Daily UAS score<sup>*</sup></h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyUASscore_1" id="cp_dailyUASscore_1">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
</select>
</div>
</div>
<h2>Day 2</h2>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyWheals_2"><h3>Daily number of wheals</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyWheals_2" id="cp_dailyWheals_2">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyPruritus_2"><h3>Daily intensity of pruritus</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyPruritus_2" id="cp_dailyPruritus_2">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row" style="background-color: #C9C1BF;">
<div class="col-sm-6">
<label for="cp_dailyUASscore_2"><h3>Daily UAS score<sup>*</sup></h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyUASscore_2" id="cp_dailyUASscore_2">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
</select>
</div>
</div>
<h2>Day 3</h2>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyWheals_3"><h3>Daily number of wheals</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyWheals_3" id="cp_dailyWheals_3">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyPruritus_3"><h3>Daily intensity of pruritus</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyPruritus_3" id="cp_dailyPruritus_3">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row" style="background-color: #C9C1BF;">
<div class="col-sm-6">
<label for="cp_dailyUASscore_3"><h3>Daily UAS score<sup>*</sup></h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyUASscore_3" id="cp_dailyUASscore_3">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
</select>
</div>
</div>
<h2>Day 4</h2>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyWheals_4"><h3>Daily number of wheals</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyWheals_4" id="cp_dailyWheals_4">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyPruritus_4"><h3>Daily intensity of pruritus</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyPruritus_4" id="cp_dailyPruritus_4">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row" style="background-color: #C9C1BF;">
<div class="col-sm-6">
<label for="cp_dailyUASscore_4"><h3>Daily UAS score<sup>*</sup></h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyUASscore_4" id="cp_dailyUASscore_4">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
</select>
</div>
</div>
<h2>Day 5</h2>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyWheals_5"><h3>Daily number of wheals</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyWheals_5" id="cp_dailyWheals_5">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyPruritus_5"><h3>Daily intensity of pruritus</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyPruritus_5" id="cp_dailyPruritus_5">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row" style="background-color: #C9C1BF;">
<div class="col-sm-6">
<label for="cp_dailyUASscore_5"><h3>Daily UAS score<sup>*</sup></h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyUASscore_5" id="cp_dailyUASscore_5">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
</select>
</div>
</div>
<h2>Day 6</h2>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyWheals_6"><h3>Daily number of wheals</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyWheals_6" id="cp_dailyWheals_6">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyPruritus_6"><h3>Daily intensity of pruritus</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyPruritus_6" id="cp_dailyPruritus_6">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row" style="background-color: #C9C1BF;">
<div class="col-sm-6">
<label for="cp_dailyUASscore_6"><h3>Daily UAS score<sup>*</sup></h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyUASscore_6" id="cp_dailyUASscore_6">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
</select>
</div>
</div>
<h2>Day 7</h2>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyWheals_7"><h3>Daily number of wheals</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyWheals_7" id="cp_dailyWheals_7">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label for="cp_dailyPruritus_7"><h3>Daily intensity of pruritus</h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyPruritus_7" id="cp_dailyPruritus_7">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
</select>
</div>
</div>
<div class="row" style="background-color: #C9C1BF;">
<div class="col-sm-6">
<label for="cp_dailyUASscore_7"><h3>Daily UAS score<sup>*</sup></h3></label>
</div>
<div class="col-sm-6">
<select class="form-control" name="cp_dailyUASscore_7" id="cp_dailyUASscore_7">
<option value="--">Select</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
</select>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label for="cp_UAS7score"><h3>UAS7 score<sup>†</sup></h3></label>
</div>
<div class="col-sm-6">
<input type="text" name="cp_UAS7score" id="cp_UAS7score" class="form-control" style="width: 100%;"></input>
</div>
</div>
<p><i>Adapted from Zuberbier et al.</i></p>
<p style="font-size: 50%;"><i><sup>*</sup>The sum of the daily number of wheals and daily intensity of pruritus.<br />
<sup>†</sup>The sum of the daily UAS scores over 7 consecutive days.</i></p>
</div>
<div class="cp_whiteBox">
<h2>Assessment of disease activity in patients with CIU (UAS scale)</h2>
<div class="row" style="background-color: #C9C1BF;">
<div class="col-sm-4">
<p style="color: ffffff;">Score</p>
</div>
<div class="col-sm-4">
<p style="color: ffffff;">Wheals</p>
</div>
<div class="col-sm-4">
<p style="color: ffffff;">Pruritus</p>
</div>
</div>
<div class="row">
<div class="col-sm-4" style="background-color: #C9C1BF;">
<p style="color: ffffff;">0</p>
</div>
<div class="col-sm-4">
<p>None</p>
</div>
<div class="col-sm-4">
<p>None</p>
</div>
</div>
<div class="row">
<div class="col-sm-4" style="background-color: #C9C1BF;">
<p style="color: ffffff;">1</p>
</div>
<div class="col-sm-4">
<p>Mild (less than 20 wheals/24 hours)</p>
</div>
<div class="col-sm-4">
<p>Mild (present but not annoying or troublesome</p>
</div>
</div>
<div class="row">
<div class="col-sm-4" style="background-color: #C9C1BF;">
<p style="color: ffffff;">2</p>
</div>
<div class="col-sm-4">
<p>Moderate (20-50 wheals/24 hours)</p>
</div>
<div class="col-sm-4">
<p>Moderate (troublesome but does not interfere with normal daily activity or sleep)</p>
</div>
</div>
<div class="row">
<div class="col-sm-4" style="background-color: #C9C1BF;">
<p style="color: ffffff;">3</p>
</div>
<div class="col-sm-4">
<p>Intense (more than 50 wheals/24 hours or large confluent areas of wheals)</p>
</div>
<div class="col-sm-4">
<p>Intense (severe pruritus, which is sufficiently troublesome to interfere with normal daily activity or sleep)</p>
</div>
</div>
<p class="cp_whiteBox" style="color: #E40178; border: 2px solid #E40178;">Remember to complete this questionnaire for your next visit with your doctor.</p>
</div>
<div class="cp_whiteBox">
<p>References:</p>
<p>1. Zuberbier T, Asero R, Bindslev-Jensen C et al. EAACI/GA(2)LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria. Allergy 2009 Oct;64(10):1417-26.</p>
<p>2. Khan DA. Chronic urticaria: Standard management and patient education. In: UpToDate, Waltham, MA. Available at <a href="http://www.uptodate.com/contents/chronic-urticaria-standardmanagement-and-patient-education">http://www.uptodate.com/contents/chronic-urticaria-standardmanagement-and-patient-education</a>. Accessed August 18, 2014.</p>
<p>3. Hide M. "Urticaria." Therapy of Skin</p>
<p>Diseases: A Worldwide Perspective on Therapeutic Approaches and Their Molecular Basis. Ed. Krieg T, Bickers DR, Miyachi Y. Springer, 2010. 247-62.</p>
</div>
</div>