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While a complete dermatologic examination is important, much of its value is in its recording. As many students are taught in veterinary school, if something isn’t documented, it didn’t happen. Too often the details of the exam don’t make their way into the medical record, which can make it difficult to reassess patients and their response to therapy. Additionally, patients frequently see multiple doctors within a practice. The more information that is provided to the next veterinarian, the better they will be able to adjust therapeutic and diagnostic plans. Details such as the percentage of stenosis of an inflamed horizontal ear canal, tail head distribution of a bacterial folliculitis, or location and size of perianal fistulae can help the next clinician, or even someone several months or years in the future.

Figure 2.9 Dog with chronic solar dermatitis. Multifocal areas of erythema and erosions with purulent exudate. The white‐skinned areas feel thickened and rough, while the black‐skinned areas palpate normally.

Much like the exam itself, there are different options for recording dermatologic findings. Many medical record systems include body map images of animals that can be marked to denote the location of different lesions. The body map can provide a quick way to assess lesion distribution and help to formulate differential diagnoses. It is also important to include a description of the different lesions, not just their location.

Another option for recording dermatologic exam findings is through written descriptions. These can be particularly helpful in complex cases with a variety of lesions. Finally, today’s electronic systems make it relatively easy to include photographs as part of the patient’s medical record. Pictures can enable a more reliable measure of improvement and can make it easier for new doctors to manage a case that has previously been treated.