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

Appendix E. Patient Diary

Directions for clinic staff: Please fill in the patient name, medical record number, and beginning date before giving this form to the patient. Please enter the day of the week on the shaded Day # 1 row (Monday, Tuesday, etc.).

Patient Name:  ______________________________________   Medical Record Number:  _____________________________

Start Date (MM/DD/YY):  ___ ___/___ ___/ ___ ___    Patient Contact Number:  _____________________________

Patient Instructions: Please fill out the information below for the next 14 days. Return this form to your provider in the attached envelope. Thanks.

Day # Day of the week Change in Infection
(Circle One for Each Day)		 Fever
(Put an X on any day you have a fever because of your skin infection.)		 Clinic Visits
(Put an X on any day you return to your clinic because of your skin infection.)		 Antibiotic Change for Your Skin Infection
(Please write the name of your new antibiotic on the day you start taking it.)		 Urgent Care or Emergency Department
(Put an X on any day you visited the ED or Urgent Care because of your skin infection.)		 Hospitalized
(Put an X on any day you were hospitalized because of your skin infection.)
Worse Same Better All Better          
1   1 2 3 4          
2   1 2 3 4          
3   1 2 3 4          
4   1 2 3 4          
5   1 2 3 4          
6   1 2 3 4          
7   1 2 3 4          
8   1 2 3 4          
9   1 2 3 4          
10   1 2 3 4          
11   1 2 3 4          
12   1 2 3 4          
13   1 2 3 4          
14   1 2 3 4          

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Page last reviewed October 2014
Page originally created September 2012
Internet Citation: Appendix E. Patient Diary. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/final-reports/mrsa/nc_mrsaape.html

The information on this page is archived and provided for reference purposes only.

 
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